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THE 


Abdominal   and   Pelvic 

Brain 


With   Automatic   Visceral    Ganglia 


BYRON   ROBINSON,  B.  S.,  M.  D. 

CHICAGO,  ILLINOIS 

Author  of  "Practical  Intestinal  Surgery,"  "Landmarks  in  Gynecology,"  "Life-size  Chart  of  the 
Sympathetic    Nerve,"  "The    Peritoneum,  its  Histology    and  Physiology',"    "Colpoperi- 
neorrhaphy  and  the    Structures    Involved,"    "The    Mesogastrium;"    Splanchnop- 
tosis, Professor  of  Gynecology  and  Abdominal  Surgery  in  the  Illinois  Medi- 
cal College;    Consulting   Surgeon  to  the    Mary  Thompson   Hospital 
for  Women  and  Children,  and  the  Woman's  Hospital  of  Chicago. 


FRANK  S.  BETZ 

HAMMOND,  IND. 


Copyright,  1907, 

BY 

BYRON    ROBINSON 


no? 


CO     I 

en 


THIS  BOOK  IS  DEDICATED  TO  THE   MEMORY 
OF   MY   FATHER 

WILLIAM   ROBINSON 

WHOSE  LIFE-LONG  PRECEPTS  WERE   INDUSTRY 
AND  HONESTY 


PREFACE. 


Where  a  truth  is  wade  out  by  one  demonstration,  there  needs  no  further  inquiry; 
but  in  all  probability  where  there  wants  demonstration  to  establish  the  truth 
beyond  doubt,  then  it  is  not  enough  to  trace  one  argument  to  its  source  and 
observe  its  strength  and  weakness,  but  all  the  arguments,  after  having  bee 
examined  on  both  sides,  must  be  laid  in  the  balance,  one  against  another; 
and  upon  the  whole  the  understanding  determines  its  assent. — John  Locke 
on  the  Conduct  of  the  Understanding. 

The  present  volume  contains  views  concerning  the  anatomy,  physiology 
and  pathology  of  the  abdominal  and  pelvic  brain.  The  abdominal  brain  is 
the  solar  or  epigastric  plexus.  The  pelvic  brain  is  the  cervico-uterine  gang- 
lion located  on  each  side  of  the  uterus. 

A  brain  is  an  apparatus  capable  of  reception,  reorganization  and  emission 
of  nerve  forces.  It  may  be  composed  of  one  or  more  nerve  or  ganglion  cells. 
The  book  is  partly  based  on  the  so-called  "reflexes,"  as  they  are  observed  in 
both  health  and  disease.  We  understand  by  "reflexes"  disturbances  which 
are  produced  in  parts  more  or  less  remote  from  points  of  local  irritation. 
The  reflex  is  the  "referred  disturbance"  of  modern  writers.  I  have  attempted 
to  show  the  extensive  utility  and  dominating  influence  of  the  abdominal  sym- 
pathetic nerves  upon  the  animal  economy.  The  reflexes  and  rhythm  con- 
cerning organs  under  various  conditions  are  discussed.  The  automatic 
menstrual  ganglia  are  presented  as  the  peripheral  ganglia  of  the  uterus  and 
oviducts.  No  attempt  has  been  made  to  divorce  the  cerebro-spinal  and 
sympathetic  nervous  systems  from  their  exquisite  mutual  dependency.  Yet, 
notwithstanding  this  latter,  the  abdominal  sympathetic  nerve,  under  observed 
conditions  of  defect  of  the  cord  and  cerebrum,  acts  with  a  certain  degree  of 
independence.  I  do  not  claim  that  deep-seated,  grave  diseases  are  caused 
by  reflex  irritation,  nor  that  these  diseases  are  dispersed  by  removal  of  the 
reflex  or  peripheral  irritation.  However,  it  may  be  stated  that  the  chief 
suffering  is  not  due  to  deep-seated  disease,  but  to  superficial,  reflex  irritation, 
which  brings  in  its  train  innumerable  disturbances  capable  of  unbalancing 
the  complex  abdominal  visceral  system. 

The  course  of  reflex  irritation  may  be  observed  clinically  as:  (1),  Per- 
ipheral (reflex,  infective)  irritation;  (2),  indigestion;  (3),  malnutrition;  (4), 
anemia;  (5),  neurosis.  The  final  stage  is  the  irritation  of  the  innumerable 
abdominal  sympathetic  ganglia  by  waste-laden  blood,  which  produces  the 
hysteria  and  neurasthenia. 

This  book  is  practically  a  treatise  on  the  abdominal  sympathetic  nerves 
(nervus  vasomotorius  abdominalis),  a  resume  of  views  which  I  have  dis- 
cussed in  current  medical  literature  for  a  decade  and  a  half. 

The  subject  of  gastro-duodenal  dilatation,  on  which  I  have  studied  and 
practiced  since  1893,  will  be  found  discussed  in  detail. 


Splanchnoptosia  is  presented  from  a  practical  viewpoint.  Its  physiol- 
ogy, anatomy,  pathology,  as  well  as  its  treatment — medical,  mechanical  and 
surgical — are  exposed  for  general  practice.  The  views  noted  in  this  book  on 
splanchnoptosia  are  the  result  of  observation  in  seven  hundred  personal 
autopsic  abdominal  inspections  and  fifteen  years  devoted  to  special  labors  in 
gynecologic  and  abdominal  surgery.  The  comparison  of  the  living  clinical 
features  of  splanchnoptosia  and  those  observed  in  the  dead  is  not  omitted.  I 
have  endeavored  to  present  a  practical  view  on  the  diagnosis  and  treatment 
of  constipation  and  sudden  abdominal  pain,  which  will  be  suggestive  to  the 
general  practitioner.  Throughout  the  book  will  be  observed  the  dominating 
influence  of  the  genital  viscera  over  all  other  viscera,  explained  by  the  mag- 
nitude of  their  nerve  supply  (pelvic  brain).  For  ten  years  I  have  attempted 
to  emphasize  and  teach  the  importance  of  knowledge  of  pathologic  physiol- 
ogy. A  short  pioneer  chapter  on  pathologic  physiology  of  abdominal  viscera 
is  introduced  to  emphasize  its  signification  and  practical  value  to  general 
physicians.  This  subject  I  have  attempted  to  teach  by  word  and  pen 
for  a  decade.  The  essay  on  diagnosis  and  treatment  of  reflex  neurosis  from 
disturbed  pelvic  mechanism  will  suggest  to  the  general  practitioner  rational 
views  of  handling  such  cases. 

In  this  book  I  wish  to  recommend  vigorously,  especially  to  the  younger 
members  of  the  profession,  what  I  term  "visceral  drainage."  By  its  sys- 
tematic, persistent  employment  the  physician  can  accomplish  vast  benefit  for 
the  patient  and  successfully  establish  a  permanently  increasing  clientele  on 
rational  treatment. 

The  chapter  on  shock  has  been  ably  and  practically  presented  by  Dr. 
Lucy  Waite,  Head  Surgeon  of  Mary  Thompson  Hospital  of  Chicago. 
Neither  time  nor  expense  has  been  spared  to  produce  accurate  and  original 
illustrations  of  practical  worth.  A  definition  of  a  structure  is  of  value,  but  a 
picture  does  it  a  thousand  times  as  well.  I  am  aware  that  the  present  vol- 
ume does  not  belong  to  the  stereotyped,  systematized  text-books ;  yet  I  am 
confident  that  the  thinking  reader  will  find  in  its  pages  ample  reward  for  its 
perusal.  It  is  also  hoped  that  since  it  is  chiefly  the  fruit  of  original  labor  it 
will  prove  of  interest  alike  to  general  practitioner  and  specialist. 

A  portion  of  this  book,  entitled  "Abdominal  Brain  and  Automatic 
Visceral  Ganglia,"  was  published  in  1899  by  the  Clinic  Publishing  Company, 
the  copies  of  which  were  exhausted  in  1904.  Numerous  repetitions  occur 
in  the  book,  arising  from  the  fact  that  each  chapter  was  written  independent 
of  the  others  and  is  practically  complete  in  itself.  Fragments  of  this  book 
were  published  in  medical  journals  such  as  the  Medical  Review  of  Revicn's, 
Medical  Age,  Medical  Brief,  Milzvaukee  Medical  Journal,  Medical  Fort- 
nightly, Medical  Review,  Medical  Record,  Medical  Standard,  Physician  and 
Surgeon,  New  York  Medical  Journal,  Alabama  Medical  Journal,  Medical 
Times,  Columbus  Medical  Journal,  America)i  Medical  Compend,  St.  Paul 
Medical  Journal,  Central  States  Medical  Monitor  and  Mobile  Medical  and 
Surgical  Journal.     Zan  D.  Klopper  is  the  artist.  Byron  Robixsox. 

Chicago,  III.,  October,   1906. 


CONTENTS. 


CHAPTER  PAGE 

I.     A  Historical  Sketch  of  the  Developmental  Knowledge  of  the  Sympathetic 

Nerves 11 

II.     Classification  of  Diseases  Which  May  Belong  in  the  Domain  of  the  Sympa- 
thetic Nerve  28 

III.  Applied  Anatomy  and   Physiology  of  the  Abdominal   Vasomotor   Nerve 

(Nervus  Vasomotorius)  33 

IV.  The  Trunk  of  the  Sympathetic  Nerves  (Nervus  Truncus  Sympathicus)  ...     39 
V.     Plexus  Aorticus  Abdominalis.     (A),  Anatomy;  (B),  Physiology 46 

VI.     The  Vasomotor  Iliac  Plexus.     Plexus  Interiliacus  Vasomotorius  (Sympa- 
thicus)       52 

VII.     The  Nerves  of  the  Tractus  Intestinalis.     Nervi  Tractus  Intestinalis.     (A), 

Anatomy ;  (B),  Physiology   62 

VIII.     The  Nerves  of  the  Tractus  Urinarius.     Nervi  Tractus  Urinarius 76 

IX.     The    Nerves    of    the    Genital    Tract.       Nervi    Tractus     Genitalis.       (A), 

Anatomy ;  (B),  Physiology 87 

X.     Nerves  of  the  Blood-vessels.      Nervi  Tractus  Vascularis.     (A),  Anatomy; 

(B),  Physiology 103 

XL     Nervus  Tractus  Lymphaticus ILL 

XII.     Abdominal  Brain  (Cerebrum  Abdominale) /T12 

XIII.  Pelvic  Brain  (Cerebrum  Pelvicum) \13L 

XIV.  General  Considerations 162 

XV.     Independence  of  the  Sympathetic  Nerve 187 

XVI.     Anatomic  and  Physiologic  Considerations 193 

XVII.     Physiology  of  the  Abdominal  and  Pelvic  Brain  with  Automatic  Visceral 

Ganglia 204 

XVIII.     Considerations  of  the  Removal  of  Abdominal  and  Pelvic  Tumors 208 

XIX.     The  Abdominal  and  Pelvic  Brain  with  Automatic  Visceral  Ganglia  in  Re- 
gard to  the  Sexual  Organs 227 

XX.     The  Automatic  Menstrual  Ganglia 240 

XXI.     Menopause 253 

XXII.     General  Visceral  Neurosis 267 

XXIII.  Relation  between  Visceral  (Sympathetic)  and  Cerebro-spinal  Nerves.  -The 

Xerve  Mechanism  of  Pelvic  and  Associated  Regions 278 

XXIV.  Hyperesthesia  of  the  Sympathetic 302 

XXV.     Motor  Neurosis 318 

XXVI.     Gastro-Intestinal  Secretion 329 

XXVII.     Secretion.     Neurosis  of  the  Colon 334 

XXVIII.     Reflex  Neurosis  from  Disturbed  Pelvic  Mechanism 340 

XXIX.     Constipation — Its  Pathologic  Physiology  and  Its  Treatment  by  Exercise, 

Diet  and  "Visceral  Drainage" 311 

XXX.     Shock 382 

XXXI.     Sudden  Abdominal  Pain — Its  Significance 398 

XXXII.     General  Pathologic  Physiology 432 

XXXIII.  Pathologic  Physiology  of  the  Tractus  Intestinalis 448 

XXXIV.  Pathologic  Physiology  of  the  Tractus  Genitalis 460 

XXXV.     Pathologic  Physiology  of  the  Tractus  Urinarius 479 

XXXVI.     Pathologic  Physiology  of  the  Tractus  Nervosus  (Abdominalis) 495 

XXXVII.     Pathologic  Physiology  of  the  Tractus  Vascularis 502 

XXXVIII.     Pathologic  Physiology  of  the  Tractus  Lympathicus 514 

XXXIX.     Splanchnoptos'ia 546 

XL.     Sympathetic  Relation  of  the  Genitalia  to  the  Olfactory  Organs 654 


THE 

Abdominal  and  Pelvic  Brain 

WITH 

AUTOMATIC   VISCERAL   GANGLIA. 


PHYSIOLOGIC    AND    ANATOMIC    CONSIDERATIONS. 


CHAPTER    I. 

A  historical  sketch  of  the  developmental  knowl- 
edge OF  THE  SYMPATHETIC  NERVES. 

The  sympathetic  nerve  presides  over  rhythm,  circulation,  sensation,  absorption, 
secretion  and  respiration — nutrition. 

"The  cloud-capped  towers,  the  gorgeous  palaces,  tlie  solemn  temples,  the  great 
globe  itself,  yea  all  which  it  inherits  shall  dissolve  and,  like  the  baseless 
fabric  of  a  vision,  leave  not  a  wreck  bcliind." — William  Shakespeare's 
epitaph,  written  by  his  own  hand,  placed  on  his  statue  in  Westminster  Abbey. 

The  sympathetic  system  of  nerves  was  discovered  by  Claudius  Galen, 
who  was  born  131  and  died  in  201  to  210  A.  D.  He  lived  first  at  Pergamos, 
and  finally  at  Rome.  Galen  considered  that  the  sympathetic  nerves  acted 
as  buttresses  to  strengthen  themselves  as  they  proceeded  from  their  origin. 
He  studied  them  in  animals  and  evidently  did  not  know  that  the  sympathetic 
nerves  were  a  part  of  the  cerebro-spinal  system.  It  appears  that  before  his 
time  the  sympathetic  ganglionic  system  of  nerves  was  entirely  unknown  as 
to  their  function  or  nature.  Yet  doubtless  Aristotle  viewed  them  many 
times  in  his  dissections,  and  wondered  what  such  white  cords  and  nodules 
signified.  It  appears  that  the  Arabians  had  some  ideas  concerning  the 
sympathetic  system. 

Galen  was  the  author  of  the  dogma  that  the  brain  was  the  place  of 
origin  of  the  nerves  of  sensation,  and  the  spinal  cord  of  those  of  motion.  In 
general  medical  literature  he  has  the  credit  of  discovering  the  sympathetic 
nerve,  and  as  Galen  was  a  practical  anatomist  (learning  his  anatomy,  how- 
ever, almost  exclusively  from  animals)  he  perhaps  gave  a  quite  accurate 
account  of  the  sympathetic,  and  this  became  quoted,  until  he  was  finally 
announced  to  be  its  father  and  discoverer.  Galen  gave  correct  views  of  the 
omentum  and  peritoneum.  He  seems  to  have  been  quite  well  acquainted 
with  the  ganglia  of  the  abdominal  nerves. 

li 


12  THE  ABDOMIXAL  AND  PELVIC  BRAIX 

It  is  claimed  that  the  sympathetic  was  known  to  the  Hippocratic  school. 
Hippocrates  (460 — 370  B.  C. ),  who  practiced  medicine  at  Athens,  Greece, 
doubtless  saw  the  sympathetic  many  times,  at  least  in  animals,  but  did  not 
interpret  its  functions.  Yet  he  was  one  of  the  first  to  cast  aside  tradition, 
which,  by  the  way,  still  lingers,  and  to  practice  medicine  on  a  basis  of 
inductive  reasoning,  just  as  a  carpenter  takes  careful  measurements  before 
building  a  house,  or  as  a  physicist  studies  astronomy. 

Erasistratus  (340 — 280  B.  C.)  believed  that  all  nerves  arise  from  the 
brain  and  cord,  but  doubtless  did  not  recognize  the  sympathetic  nerves  as 
such.  It  appears,  however,  that  he  separated  nerves  into  those  of  motion 
and  sensation.     He  studied  particularly  the  shape  and  structure  of  the  brain. 

Herophilus  (300  B.  C. ),  it  appears,  dissected  more  than  all  his  predeces- 
sors, both  in  man  and  animals.  He  was  the  first  to  distinguish  nerves  from 
tendons,  which  Aristotle  confounded.  Herophilus  gave  the  duodenum  its 
name  because  it  is  twelve  inches  or  finger  breadths  in  length.  He,  like 
Erasistratus,  distinguished  nerves  of  motion  from  those  of  sensation,  and 
added  a  careful  study  of  the  brain.  We  all  remember  his  "Torcular 
Herophili, "  or  wine-press. 

Aristotle  (384  B.  C),  who  widely  dissected  animals  while  instructing 
Alexander,  the  son  of  King  Philip,  no  doubt  saw  the  sympathetic  system 
frequently,  yet  did  not  interpret  its  significance,  for  he  confounded  tendons 
and  nerves. 

B.  Eustachius,  an  Italian  anatomist,  who  died  in  1574,  considered  that 
the  sympathetic  nerves  originated  from  the  abducens  or  sixth  cranial  nerve. 
It  was  not  until  the  name  of  Thomas  Willis  (1622-1675),  an  English 
physician,  appeared  in  anatomical  records  that  the  proper  significance  of  the 
sympathetic  nerves  was  recognized.  Willis  looked  on  the  sympathetic 
system  of  nerves  as  an  appendage  of  the  cerebrospinal  system  and  repre- 
sented them  as  growing  from  the  cerebrospinal  nerves.  Many  neurologists 
hold  the  same  opinion  today  as  did  the  able  Willis  two  hundred  and  fifty 
years  ago.  He  looked  upon  the  sympathetic  nerves  as  a  kind  of  diverticula 
for  the  animal  spirits  received  from  the  brain.  In  1660,  while  Sedleian 
professor  of  philosophy  at  Oxford,  he  described  the  chief  ganglia. 

Rene  Descartes  (1569-1650)  was  one  of  the  first  to  describe  reflex  move- 
ments from  ganglia. 

R.   Yieussens  (1641-1716),   a    French    anatomist,  wrote  a   work  entitled 

Fig  1.  It  presents  a  general  view.  1  and  2,  abdominal  brain.  B  represents  the  pelvic 
brain  or  ganglion  cervicale.  Observe  the  profound  and  intimate  connection  between  the 
abdominal  brain  (1  and  2)  and  the  pelvic  brain  (B)  by  means  of  the  plexus  aorticus  (10  and 
12)  and  plexus  hypogastrics  (H).  Note  the  lateral  chain  of  the  sympathetic  ganglia  from  the 
cervical  ganglia  (1)  to  the  last  sacral  ganglion  (S  G).  1  and  2,  abdominal  brain,  is  the  major 
assembling  point  of  the  plexuses  of  the  abdomen.  Observe  the  plexus  aorticus  with  its  mul- 
tiple ganglia  and  two  lateral  cords  extending  from  the  abdominal  brain  (1  and  2)  to  the 
bifurcation  of  the  aorta.  Next  note  the  hypogastric  plexus,  beginning  at  the  aortic  bifurca- 
tion and  ending  practically  in  the  pelvic  brain  (B).  H,  the  hypogastric  ganglion  is  a  coal- 
esced, unpaired  organ.  The  major  sympathetic  ganglia  are  located  at  the  origin  of  arteries, 
hence  every  abdominal  visceral  artery  has  at  its  origin  a  definite  ganglion.  In  drawing  the 
pelvic  brain  suggestions  of  Frankenhauser  were  employed.  The  dissection  was  performed 
under  alcohol. 


Fig.  1.    AN  ILLUSTRATION  OF  THE  SYMPATHETIC  NERVE 


14  THE  ABDOMINAL  AND  PELVIC  BRAIN 

"Neurograph"  in  1684,  in  which  he  adopted  the  views  of  Willis,  that  the  gan- 
glionic nerves  were  appendages  of  the  cerebrospinal  system. 
Vieussens  wrote  of  the  ganglia  of  the  solar  plexus. 
Prochaska  described  the  reflex  channels. 
Duverney  (1643-1730)  discovered  the  ciliary  ganglia. 
J.  M.  Lancisus  (1654-1720),  an  Italian  anatomist,  wrote  a  monograph  on 
the  sympathetic  nerves,  agreeing  with  the  keen  Willis  as  regards  structure. 
His  monograph  was  entitled  "Opera  Omnia."     Lancisus  looked  upon  the 
sympathetic  nerves  as  a  kind  of  forcing  pump  adapted  to  propel  the  animal 
spirits  along  the  nerves. 

The  senior  Johann  Friedrich  Meckel  (1714-1774),  in  his  "Memories  de 
Berlin,"  1745,  held  views  on  the  subject  of  the  sympathetic  nerves  similar  to 
those  of  Willis,  as  did  also  Johann  Gotfried  Zinn  (1727-1759)  in  a  publica- 
tion in  1753. 

J.  B.  Winslow  (1669-1760),  a  Dane,  professor  of  anatomy  in  Paris, 
insisted  in  his  writings  on  the  independence  of  the  sympathetic  nerves. 
Since  that  time  writers  have  wavered  between  the  opinions  of  Winslow 
(independence)  and  Willis  (dependence)  in  regard  to  the  sympathetic  nervous 
system.  Yet  up  to  one  hundred  years  ago  actual  physiologic  and  experi- 
mental data  were  quite  limited.  Bichat,  who  widely  influenced  the  anatomic 
world,  vigorously  proclaimed  the  independence  of  the  sympathetic  ganglia. 

Hoare  wrote  a  publication  in  1772  on  the  sympathetic  system  entitled 
"De  Ganglia  Nervorum." 

Antoine  Scarpa  (1752-1832),  the  Italian  anatomist  of  "Scarpa's Triangle" 
fame,  wrote  an  essay  on  the  sympathetic  system  entitled  "De  Nerv.  Gangl." 
in  1779.     This  work  of  course  contained  the  views  of  previous  writers. 

Alexander  Monro  (Monro  secundus,  1733-1817),  a  Scotch  anatomist  of 
Edinburgh  University,  published  an  essay  "On  the  Structure  and  Function  of 
the  Nervous  Ganglia,"  in  1783.  The  later  writers  analyzed  more  in  detail 
and  generalized  in  a  manner  superior  to  that  of  previous  writers,  yet  all 
agreed  or  disagreed  with  Willis  or  Winslow. 

Johann  Friedrich  Blumenbach  (1752-1840),  a  German  anatomist,  in 
"Institutes  of  Physiology,"  published  views  on  the  sympathetic  nerves  in 
1786. 

Francois  Chaussier  (1746-1828),  a  French  surgeon  and  anatomist,  wrote 
an  "Exposition"  of  the  sympathetic  nerves  in  1807. 

In  1812  Le  Gallois  wrote  "Sur  le  Principe  de  la  Vie,"  containing  views 
on  the  sympathetic  nerve. 

In  1823  views  of  the  sympathetic  nerve  appeared  in  Beclard's  "El. 
d'Anat.  Gen." 

Georges  Cuvier  (1769-1832),  a  famous  French  naturalist,  espoused  the 
doctrine  of  the  independence  of  the  sympathetic  nervous  system  as  published 
in  his  "Lecons  d'Anat.  Comp.,"  1799. 

Xavier  Bichat  (1771-1802),  the  master  intellect  of  his  day  in  Paris, 
professor  of  anatomy  and  physiology,  the  associate  and  rival  of  the  priestly 
physician,    Pinel,    may   be   heard  insisting  with  his  accustomed  eloquence 


DEVELOPMENTAL  KNOWLEDGE  OF  SYMPATHETIC  NERVES  15 

upon  the  independence  of  the  sympathetic  nervous  system,  as  noted  in  his 
"Sur  la  Vie  et  la  Mort.,"  1802.  Bichat  represented  all  the  ganglia  of  this 
system  as  the  particular  centers  of  organic  life,  that  not  only  were  all  the 
ganglia  collectively  independent,  but  that  each  ganglion  was  independent  of 
rvery  other  ganglion,  that  each  nerve  proceeding  from  such  a  ganglion  was 
in  a  great  measure  independent  from  that  ganglion,  and  even  that  each  point 
of  such  a  nerve  was  independent  of  all  the  rest  and  consisted  of  a  distinct 
focus  of  nervous  influence.  Bichat's  influence  is  distinctly  traceable 
through  subsequent  writings  on  the  sympathetic  system. 

Wilson  Philip  wrote  "On  the  Vital  Functions,"  in  1817,  analogous  to  the 
grand  center  of  animal  life.  He  also  held  views  referring  to  the  sympathetic 
system. 

In  Mason  Good's  work  "On  the  Study  of  Medicine, "  1825,  views  are 
expressed  in  regard  to  the  sympathetic  nervous  system. 

Writers  on  the  sympathetic  system  became  more  numerous  in  the  period 
subsequent  to  1800. 

Richerand  (Phys.  1804),  and  Gall  (Anat.  et  Phys.  du  Syst.  Nerv.,  1810), 
adopted  tenets  concerning  the  sympathetic  nervous  system  similar  to  those  of 
Bichat. 

Wurtzer  in  1817  (De  Corp.  Hum.  Gang.)  further  inculcated  Bichat's, 
Winslow's  and  Cuvier's  views. 

Broussais,  whose  name  is  indelibly  connected  with  inflammation  of  the 
peritoneum  as  Bichat's  is  with  establishing  the  independence  of  the 
sympathetic,  describes  a  peculiar  kind  of  sensibility  or  irritability  belonging 
to  the  sympathetic  nerves  with  which  it  immediately  endows  all  organs 
destined  for  nutrition,  secretion  and  the  other  organic  functions,  and,  by 
means  of  its  repeated  connections  with  the  cerebrospinal  system,  all  organs 
of  the  body. 

Brachet,  in  his  "Sur  les  Fonctions  du  Syst.  Nerv.  Gang.,"  1823,  in  an 
especial  manner,  distinctly  represents  the  ganglionic  system  of  nerves  as  the 
seat  of  "imperceptible  sensation"  and  as  presiding  in  an  especial  manner 
over  the  several  viscera  of  the  body.  The  author,  though  not  acquainted 
with  Richerand's  and  Bichat's  views,  worked  out  the  same  views  from  orig- 
inal studies  and  experiments,  but  added  the  idea  that  the  abdominal  brain 
(solar  plexus)  is  the  chief  organizing  center  of  the  abdominal  sympathetic. 

The  preceding  views  are  simply  some  of  the  chief  landmarks  in  the 
progress  of  the  evolutionary  development  of  the  knowledge  of  the  sympa- 
thetic nerves,  in  the  direction  of  their  function  and  signification. 

The  most  significant  names  among  the  brilliant  galaxy  of  students  of 
the  sympathetic  nerves  are  Willis,  Bichat,  Cuvier,  Winslow  and  Brechet. 

In  1835  articles  on  the  sympathetic  nerves  began  to  appear  from  the  pen 
of  James  George  Davy,  of  London,  England,  which  study  and  writing  on 
the  sympathetic  he  continued  for  about  thirty  years.  In  1858  the  same 
author  published  a  book  "On  the  Ganglionic  Nervous  System."  The  work 
is  composed  of  109  pages,  is  interestingly  written  and  contains  about  all  the 
real  knowledge  of  the  subject  up  to  that   date  (1858).     Davy   claimed   that 


16  THE  ABDOMINAL  AND  PELVIC  BRAIN 

much  of  his  book  was  original,  and  doubtless  this  industrious  worker  produced 
many  new  views  in  thirty  years  of  labor.  Yet  Davy,  as  we  view  him  forty 
years  past,  appears  very  honest  in  that  he  credits  the  gifted  Bichat  with  so 
many  original  views  and  vast  conceptions.  The  writer  can  only  hope  that 
readers  forty  years  hence  will  view  this  present  little  volume  with  similar 
candor  and  charity. 

Bichat's  genius  established  in  medical  literature  the  sympathetic  nerves 
under  the  names  "organic  and  vegetative"  system,  because  he  saw  analogies 
between  the  nerves  which  preside  over  viscera  (and  hence  nutrition)  and  the 
life  of  plants.  He  considered  that  the  sympathetic  nerves  induce  an  animal 
to  live,  assimilate  and  nourish,  induce  circulation  and  excretion — in  short 
to  have  an  habitual  succession  of  assimilation  and  excretion  sufficient  to 
preserve  life's  integrity  by  a  vital  inherent  process.  No  effort  was  required 
of  the  animal — all  was  done  in  the  so-called  sub-conscious  region,  by  what 
we  might  call  today  unconscious  or  imperceptible  sensation.  It  is  especially 
the  sub-conscious,  the  imperceptible  traumatic  insults  of  pathologic  processes 
among  viscera,  which  the  writer  will  attempt  to  elucidate. 

Bichat  paved  the  way  for  a  more  ready  appreciation  of  the  physiology  of 
the  sympathetic  system.  Dr.  Grant,  a  writer  of  some  sixty  years  ago,  said 
that  "the  sympathetic  nerves,  appropriated  to  the  more  slow  and  regular 
movements  of  organic  life,  form  a  more  isolated  system"  (than  the  cerebro- 
spinal). It  appears  that  Dr.  John  Fletcher  wrote  learnedly  on  the  sympa- 
thetic system  in  his  "Rudiments  of  Physiology,"  published  in  1837,  for  in 
May,  1853,  Dr.  Davy  read  an  essay  "On  the  Physiologic  Uses  of  the 
Ganglionic  Nervous  System"  before  the  London  Medical  Society,  whereupon 
M.  Walford,  of  Reading,  addressed  a  curt  note  to  Dr.  Davy  informing  him, 
politely,  that  it  was  Dr.  Fletcher  who  deserved  the  credit  of  "establishing 
on  an  immutable  basis  the  function  of  the  great  sympathetic  nerves."  Davy 
very  honestly  relates  how  he  sent  a  paper  on  the  sympathetic  nerve  to  the 
Lancet,  but  the  editor  not  only  rejected  it,  but  did  not  return  the  manuscript. 
This  was  in  1836.  The  strife  concerning  priority  in  regard  to  views  upon 
the  divisions  of  the  nervous  system  was  very  active  some  sixty  years  ago. 
Among  the  participants  might  be  named  Marshall  Hall,  Robert  Reid,  Davy, 
Gall,  Brechet,  Blane,  Mayo  and  others.  However,  one  and  all  bowed 
before  the  magnificent  intellect  of  Bichat.  Bichat  located  the  passions  in 
the  "epigastric  center,"  and  believed  that  they  belong  to  the  sympathetic 
nerves.  Bichat's  opinion  dominated  medical  ideas  for  three-quarters  of  a 
century  after  his  death.  Buffon,  Cabanis,  Reil  and  Broussais,  contem- 
poraries of  Bichat,  located  the  passions  in  "the  Viscera  of  the  Chest  and 
Belly,"  or  represented  them  as  belonging  to  the  ganglionic  system  of  nerves. 

The  labors  of  Morgagni  and  Petit  (1827)  should  be  mentioned,  as  well  as 
those  of  Bergen  (1731),  Walter  (1783),  Huber  (1774),  Gerald  (1754),  Weber 
(1831),  Rudolphi  (1818),  Lobstein  (1823)  (nerve  tables),  Manee  (1828), 
Radcliff  (1846),  Hall  (1847),  Moses  Gunn,  inaugural  thesis  (1846),  Robin 
(1847),  Wagner  (1847),  and  Axmann  (1847).  Valentin,  Kraus  (1857),  Bourgery 
(1845),    Arnold    (1826),    Andersch,    Haller,    Wrisberg,    Sommering,    Remak, 


DEVELOPMENTAL  KNOWLEDGE  OE  SYMPATHETIC  NERVES  17 

Muller,  Lee  (Frankenhauser,   1867),   and  Baker  are  but  some  of  the  many 
workers  in  the  field  of  the  sympathetic. 

Todd  and  Bowman  named  the  solar  plexus  'the  abdominal  sympathetic 
system"  (1847).  Solly  called  the  solar  plexus  "the  center  of  the  cyclo- 
ganglionic  system"  (1848).  There  is  little  doubt  that  to  Bichat  is  due  the 
credit  of  originating  the  doctrine  of  the  entirety  and  independence  of  the 
sympathetic  nervous  system.  Later  writers,  as  Cuvier,  Richerand,  Gall, 
Wurtzer,  Broussais,  Brechet,  Solly  and  Fletcher,  have  taught  similar  views. 
Many  older  neurologists  divided  the  nervous  system  into  three  distinct 
divisions,  viz. :     (a)  cerebral,  (b)  spinal  and  (c)  sympathetic. 

Le  Gallois,  a  noted  neurologist,  taught  that  the  spinal  cord  was  the 
source  of  a  part  of  the  ganglionic  nervous  system,  but  Davy  strenuously 
denies  Le  Gallois'  assertion  and  remarks  that  the  medical  profession  never 
acknowledged  it.  About  1840  no  less  distinguished  a  person  than  Marshall 
Hall  asserted  that  in  the  removal  of  the  frog's  viscera  "every  portion  of  the 
ganglionic  system"  would  also  be  removed.  This  showed  lack  of  anatomical 
knowledge.  But  by  1840  such  writers  as  Cuvier,  Solly,  Bichat,  Richerand, 
Wurtzer,  Gall  and  Broussais  claimed  that  every  ganglion  of  the  sympathetic 
was  independent  of  the  remainder  and  that  each  ganglion  is  a  distinct  focus 
of  nervous  influence.  It  was  Broussais  (the  founder  of  the  idea  of  independ- 
ent peritoneal  inflammation)  who  claimed  that  the  ganglia  presided  over  the 
viscera  and  their  functions. 

Prochaska  and  John  Hunter  asserted  that  the  ganglia  of  the  sympathetic 
nervous  system  generate  and  control  nervous  power.  Any  one  can  witness 
this  fact  by  separating  a  frog  from  its  heart.  The  heart  will  beat  for  hours 
alone.  The  cerebrospinal  nerves  together  perform  the  animal  functions 
which  prove  us  to  be  feeling  and  thinking  and  willing  beings. 

The  ganglionic  system  of  nerves,  with  the  abdominal  brain  as  their 
central  organ,  performs  the  vital  functions,  which  are  independent  of  mind 
and  present  to  us  the  idea  of  life.  The  sympathetic  system  of  nerves 
presides  over  the  viscera — over  secretion,  nutrition,  gestation,  expulsion, 
respiration  and  circulation;  over  sub-conscious  phenomena. 

Muller,  Bayly,  Rolando,  Akermann,  Blumenbach  and  Gall  agreed  to  the 
following  views  (by  1840),  viz. :  The  sympathetic  system  of  nerves  of  the 
chest  and  abdomen  are  fully  formed  while  the  brain  is  yet  a  pulpy  mass. 
Now,  these  ganglia  of  the  sympathetic  would  hardly  be  formed  before  the 
brain  and  cord  if  it  were  not  for  the  sake  of  the  organs  which  they  supply 
and  rule.  Besides,  it  may  be  added  that  the  sympathetic  controls  the 
viscera,  which  are  as  perfect  at  birth  as  in  the  adult.  But  the  mind  and 
brain  are  very  slowly  perfected.  The  priority  of  the  sympathetic  nerves  over 
the  cerebrospinal  is  evident  and  signifies  their  import  in  the  continuance  of 
the  vital  forces  of  life.  Babies  are  born  alive  with  no  brains.  Dr.  Ball,  of 
Ohio,  writes  me  that  he  found  one  baby  fully  formed  without  even  a 
medulla  oblongata.  Marshall  Hall  records  that  a  fetus  was  born  "without 
either  a  brain  or  spinal  marrow,  without  a  particle  of  either  of  those  organs, 
yet  perfectly  developed."      Blumenbach  furnishes  an  equal  example,  when 

2 


18  THE  ABDOMINAL  AND  PELVIC  BRA1X 

he  says,  "In  fetuses  without  brain  or  spinal  marrow  the  circulation,  nutrition, 
secretion,  etc.,  proceed  equally  as  in  others,  who,  besides  spinal  marrow, 
nerves  and  ganglionic  nervous  system,  possess  a  brain." 

Children  are  born  quite  well  developed  without  the  vestige  of  a  cerebro- 
spinal system, — only  possessing  a  sympathetic  system.  It  might  be  argued 
that  often  these  children  originally  possessed  a  cerebrospinal  system,  but 
that  through  pressure,  as  hydrocephalic  conditions,  the  fluid  had  pressed 
the  nerve-cells  out  of  existence.     Yet  this  does  not  explain  all  the  cases. 

In  1872  there  appeared  one  of  the  best  and  most  reliable  books  on  the 
sympathetic  system  of  nerves  up  to  that  date.  The  authors  are  Guttmann 
and  Eulenberg.  It  was  translated  from  the  German  into  the  English  in  1878 
by  Dr.  C.  Napier.  This  work  was  based  on  physiologic  and  pathologic 
labors.  It  was  for  this  essay  of  Eulenberg  and  Guttmann  that  the  Astley 
Cooper  Prize  for  1877  was  originally  awarded — a  decision  which  was  subse- 
quently overthrown,  however,  on  the  technical  ground  that  the  essay  was  the 
work  of  two  authors  and  not  one  only,  as  the  terms  of  Sir  Astley  Cooper 
would  seem  to  require. 

In  1802  William  Hunter  presented  the  nerves  of  the  uterus.  The 
Osianders,  father  and  son,  also  did  similar  work  in  1808-1818.  Tiedemann 
(1822)  made  valuable  observations  on  uterine  nerves.  Lobstein,  in  1823, 
produced  excellent  views  on  the  sympathetic.  He  carefully  described  the 
various  plexuses  by  the  names  we  now  give  them. 

In  1839  Robert  Lee  gave  some  good  descriptions  of  the  sympathetic 
uterine  nerves,  as  also  Snow  Beck  (1845)  with  Clay,  Goetz,  Schlem,  Swan 
1846),  Killian  (1834)  and  Lambell  (1841). 

In  1867  a  most  excellent  work  was  published  by  Dr.  F.  Frankenhauser, 
entitled:  "The  Nerves  of  the  Uterus."  It  contains  finely  executed  tables  of 
the  sympathetic  nerves  of  the  abdomen. 

The  sympathetic  nervous  system  is  shown  to  be  supremely  evident  when 
we  note  the  body  nourished,  the  viscera  perfected  and  the  bony  structures 
finished,  without  a  brain  or  cord,  and  still  more  evident  when  we  observe 
the  finely  balanced  circulation,  delicate  absorption  and  secretion,  in  full  and 
perfect  operation  for  nearly  a  year  without  a  cord  or  brain — only  a  sympa- 
thetic nervous  system  to  rule.  Should  the  main-spring  of  life,  the 
abdominal  brain,  solar  ganglion,  cease  its  activity,  then  life  itself  disap- 
pears. The  sympathetic  nerves  carry  on  life's  functions  during  sleep,  like 
the  additional  spring  to  a  watch  which  enables  it  to  go  while  being  wound. 

By  1850  the  physician  had  not  lost  sight  of  the  fact  that  the  sympathetic 
nerve,  being  so  intimately  associated  with  the  vital  action  of  every  viscus, 
could  become  involved  in  disease.  For  the  past  fifty  years  the  pathology  of 
the  sympathetic  has  been  studied.  In  the  work  of  Davy  may  be  found 
numerous  diseases  attributed  to  the  sympathetic.  Dr.  Marshall  Hall  stated 
that:  "The  ganglionic  system  is  that  power  under  which  all  formation,  all 
nutrition,  all  absorption  and  all  secretions  are  performed;  therefore,  that 
being  affected  may  affect  different  acts." 

The  opinions  of  men  famous,  though  dead,  still  prevail.     Bidder  produced 


developmhxt.il  knowledge  OFSYMPATHETIC  NERVES  19 

a  celebrated  article,  in  Midler's  Archives  for  Physiology,  in  1844,  entitled: 
"Experience  over  the  Functional  Independence  of  the  Sympathetic  as  the 
Center  of  Motion  and  Sensation  for  all  the  Vegetative  Organs."  Volkmann 
assumed  the  same  views  as  Bidder  in  his  well-known  article:  "The  Inde- 
pendence of  the  Sympathetic  Nervous  System  Demonstrated  through 
Anatomical  Investigations"  (1842).  Prof.  Albert  V.  Kolliker,  of  Wurtzburg, 
who  is  now  celebrating  his  fifty-year  jubilee  as  a  medical  teacher,  assumed 
an  intermediate  ground  between  Bidder  and  Volkmann,  when  in  1845  he  wrote 
his  article  entitled,  "The  Independence  and  Dependence  of  the-  Sympathetic 
Nervous  System  Demonstrated  by  Anatomical  Observation."  Budge  in  1864 
gave  some  reliable  data  in  regard  to  the  nerves  of  the  bladder,  in  Henle's 
and  Pfeufer's  "Landschrift  fur  rational  Medicin, "  as  did  also  Gianozzi  in 
1863. 

The  history  of  the  developmental  knowledge  of  the  sympathetic  is  not 
complete  without  the  names  of  Schiff,  Henle,  Ludwig,  Heffer  and  especially 
the  often-quoted  experiments  of  Nasse  found  in  his  article:  "Lecture  on  the 
Physiology  of  Bowel  Motion,"  Leipsic,  1866.  Henle  stated,  in  1840,  that 
the  peristalsis  of  the  intestines  was  due  to  ganglia  scattered  among  the 
intestinal  nerves.  Brown-Sequard,  Pickford,  Remak  (1864),  Jastrowitz 
(1857,)  Rochefontaine,  Tarchanoff,  Pflueger,  Bernard,  Golz  and  Knoll  aided 
in  the  building  of  the  present  knowledge  of  the  sympathetic. 

In  1860  DuBois-Reymond  inferred  that  migraine  was  due  to  the  influence 
of  the  cervical  part  of  the  sympathetic,  i.  e.,  it  produced  a  kind  of  tetanic 
contraction  of  the  vessels,  showing  the  influence  of  the  sympathetic  over 
vessels.  He  styled  it  Hcmicrania  sympathetica  atonica.  Cruveilhier  and 
Aran  are  credited  with  discovering  muscular  atrophy,  but  Charles  Bell  (1832) 
gives  several  cases.  Bell  places  muscular  atrophy  under  the  domain  of  the 
sympathetic.  Parry  (1825)  discovered  a  group  of  symptoms  which  we  now 
call  exophthalmic  goiter  (Graves'  or  Basedow's  disease)  which  many  place  in 
the  field  of  the  sympathetic  nerve.  The  three  great  symptoms  are  (a) 
cardiac  palpitation,  (b)  goiter  and  (c)  finally  exophthalmos.  Basedow  (1840) 
claimed  to  have  first  described  the  disease,  but  the  priority  of  Graves  is  now 
universally  known. 

Angina  Pectoris,  described  by  Heberden  in  1768,  is  considered  by  many 
as  caused  by  the  sympathetic  nerves,  especially  the  three  cervical  ganglia 
and  the  cardiac  plexuses.  Addison's  disease  is  placed  by  some  in  the  field  of 
the  sympathetic. 

In  1783  Walter  presented  the  best  tables  of  the  sympathetic  nerves  up 
to  his  day.  It  appears  that  Walter  was  the  first  who  represented  in  his 
cuts  the  cervico-uterine  ganglia,  i.  e.,  lateral  ganglia  of  the  uterus. 

The  above  authors  discuss  in  a  very  instructive  method  the  various 
diseases  of  the  sympathetic  and  attempt  to  establish,  as  far  as  possible,  the 
physiologic,  anatomic  and  pathologic  limits  of  the  domain  of  the  sympathetic 
nerves.  Especially  interesting  and  valuable,  though  unfortunately  limited, 
are  the  discussions  upon  the  abdominal  parts  of  the  sympathetic. 

Eulenberg  and  Guttmann  discuss  as  belonging  to  the  domain  of  the 
sympathetic  system,  the  following  diseases: 


20  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

1.  Functional  disturbances,  especially  those  dae  to  irritation  and  paraly- 

sis. 

2.  Unilateral  Hyperidrosis  (perspirat  .:>n) 

3.  Hemicrania  i  neuralgia  i. 

4.  Glaucoma  (Nenro-retinitis,  ophthalmia,  neuro-paralytica). 

5.  Progressive  Facial  Hemiatrophy. 

6.  Progressive  Muscular  Atrophy. 

7.  Exophthalmic  Goiter  (Basedow's  or  Graves'  disease). 

8.  Angina  Pectoris  (steno-cardi:.  . 

9.  Addison's  disease  (bronzed  skin). 

10.  Diabetes  Mellitus. 

11.  Hyperesthesias  of  the  sympathetic  system: 

(a)  Enteralgia,  enterodynia,  colic. 

(b)  Neuralgia  celiaca. 

(c)  Neuralgia  hypergastrica. 

(d)  Neuralgia  spermatica  (ovarica). 

12.  Anesthesias  of  the  sympathetic  system  ''not  well  established). 

13.  Sympathetic  paralysis  and  spasmodic  affections  of  voluntary  muscles. 
Reflex  paralysis,  diphtheritic  paralysis,  tabes  dorsalis  (.locomotor  ataxia, 
progressive  . 

The  above  thirteen  classes  of  disease  discussed  as  belonging  to  the 
domain  of  the  sympathetic  nerves  have  remained  a  more  cr  less  constant 
quantity  with  writers  on  the  sympathetic  nerve.  However,  some  writers 
add,  others  subtract,  while  still  others  change  the  names  of  the  above 
diseases.     The  subject  is  in  a  state  of  progress. 

In  1867  Griesinger  began  investigations  on  the  "Pathology  of  the 
Sympathetic."  Griesinger's  enthusiasm  stimulated  two  physicians,  Dr.  Paul 
Guttmann  and  Dr.  Albert  Eulenberg,  to  produce  one  of  the  best  and  most 
reliable  books  on  the  pathology  of  the  sympathetic  based  on  physiologic 
grounds  ever  published.  Griesinger's  good  work  and  enthusiasm  were 
productive  of  practical  results:  for  his  remarkable  words,  that  "our  positive 
knowledge  of  the  pathology  of  the  sympathetic  should  be  again  collected 
by  skilled  hands,"  induced  his  scholars,  Eulenberg  and  Guttmann,  to  study 
and  write  their  prize  book  on  the  sympathetic  nerves. 

In  1876  a  very  learned  and  a  very  instructive  essay  appeared  from  the 
^en  of  Dr.  Sigmund  Mayer,  entitled,  "Die  Peripherische  Nerven  Zellen  und 
das  Sympathetische  Nerven  System. "  Dr.  Mayer  was  full  five  years  engaged 
in  the  work  in  his  microscopical  laboratory  and  presented  many  interest- 
ing ideas  and  some  of  the  most  suggestive  drawings  of  the  nerves  and  cells. 
The  essay  represents  many  new  views  and  vast  labors. 

In  1881  there  appeared  the  "Fisk  Fund  Prize  Essay,"  Rhode  Island 
Medical  Society — "The  Sympathetic  Nerve;  its  Relation  to  Diseases,"  by 
C.  V.  Chapin.  M.  D.  This  is  a  valuable  essay,  as  it  gives  many  authorities 
and  references  which  enable  us  to  enlarge  our  knowledge  of  this  nerve.  Dr. 
Chapin  has  sifted  out  the  theoretical  and  practical  knowledge  of  the  nerve 
quite  well.      Chapin  has  but  little  deviation  from  the  classification  of  the 


DEVELOPMENTAL  KNOWLEDGE  OF  SYMPATHETIC  NERVES  21 

diseases  which  belong  to  the  sympathetic  of  Eulenberg  and  Guttmann.  An 
epitome  of  Chapin's  book  would  be,  that  it  is  a  record  of  opinions  on  the 
sympathetic  nerve  skilfully  collected  and  arranged  in  a  scholarly  manner. 

In  1885  Dr.  W.  H.  Gaskell  published  the  results  of  some  excellent  labor 
on  the  sympathetic  system  of  nerves.  One  of  the  best  was  entitled:  "The 
Structure,  Distribution  and  Function  of  Nerves  which  Innervate  the  V'^ceral 
and  Vascular  Systems."     Dr.  Gaskell  noted  some  of  the  following  p-j.nts: 

1.  The  visceral  nerves  issue  from  the  central  nervous  system  indefinite 
sacral,  thoracic  and  cervico-cranial  regions. 

2.  From  the  above  regions  the  visceral  nerves  pass  through  the  ganglia 
into  the  visceral  system. 

3.  From  the  sacral  region  they  pass  in  a  single  stream  to  the  ganglia  of 
the  collateral  chain. 

4.  From  the  thoracic  region  they  pass  in  a  double  stream,  one  to  the 
ganglia  of  the  lateral  chain,  the  other  to  the  ganglia  of  the  collateral  chain. 

5.  From  the  upper  cervical  region  they  pass  in  a  single  stream  to  the 
ganglia  on  the  main  stem  of  the  vagus  and  glosso-pharyngeal  nerves. 

Gaskell's  labors  on  the  sympathetic  are  of  far-reaching  value  and  their 
utility  has  been  recognized  by  being  copied  very  generally,  and  even  in  detail, 
in  the  best  modern  works  on  physiology. 

Rauber  did  some  excellent  work  on  the  sympathetic,  and  his  labor  is 
recognized  by  Quain's  latest  edition  borrowing  one  of  his  cuts. 

In  1885  Dr.  Edward  Long  Fox  published  a  well-written  and  very 
instructive  book  on  "The  Influence  of  the  Sympathetic  on  Disease."  This 
is  the  most  comprehensive  of  late  books  on  the  sympathetic.  He  widens 
the  influence  of  the  sympathetic  in  the  domain  of  disease  beyond  that  laid 
down  by  Eulenberg  and  Guttmann.  He  includes  insomnia,  neurasthenia, 
pigmentation,  myxedema  and  neuroses  of  the  extremities — symmetrical 
gangrene.  The  writer  can  highly  recommend  Dr.  Fox's  book  as  instructive 
and  valuable.  Articles  of  merit  and  value  on  the  sympathetic  nerves  have 
appeared  with  increasing  frequency  during  the  past  ten  years. 

In  1877  Gubler  described  a  morbid  symptom  of  the  peritoneum  related 
to  the  sympathetic  system.  He  called  it  peritonismus.  He  included  pain, 
meteorismus  in  various  degrees,  hiccough,  vomiting,  rapid  pulse,  cyanosis, 
lowering  of  the  temperature,  cerebral  symptoms  of  great  activity,  depression 
of  mental  powers  and  decrease  of  amount  of  urine.  The  nerves  of  the  heart 
are  affected.  This  aggregate  of  symptoms  Gubler  designated  by  the  word 
peritonismus.  The  abdominal  surgeon  only  too  frequently  sees  this  clinical 
picture,  but  it  is  doubtful  how  much  is  gained  by  designating  it  as  perito- 
nismus. , 

THE  PELVIC  BRAIN. 

(A.)     Macroscopic. 

From  the  stately  rhythm  and  periodic  peristalsis  of  the  uterus  in  labor, 
the  early  observer  must  have  been  impressed  with  the  nerves  governing  the 
genitals.     However,  from  the  unfortunate  dogma  of  the  church,  the  light  of 


22  THE  ABDOMINAL  AND  PELVIC  BRAIN 

knowledge  of  anatomy  and  physiology  was  denied  mankind  by  prohibiting 
human  dissection.  So  far  as  I  have  been  able  to  note  almost  all  observations 
on  the  nerves  of  the  genitals  (uterus),  previous  to  the  fifteenth  century,  were 
almost  valueless. 

Among  the  first  names  I  find  in  literature  referring  to  the  nerves  of 
the  uterus  is  that  of  A.  Vesalius,  a  Belgian  by  birth,  professor  of  anatomy 
at  the  famous  school  of  Padua,  Italy.  He  was  born  in  1514  and  died  in  1564. 
Vesalius  made  the  general  statement  (partly  false  and  partly  true)  that 
the  cervix  was  supplied  by  the  sacral  nerves  (spinal)  while  the  fundus  was 
supplied  by  the  sympathetic. 

This  view  of  Vesalius  generally  prevailed  for  two  centuries  and  was 
practically  confirmed  by  the  following  famed  eponymic  names  on  anatomy: 
Eustachius  (died  1574),  Reignier  de  Graaf  (1641-1673),  Thomas  Willis 
(16-22-1675),  Albert  Haller  (1708-1777),  Johann  G.  Walter  (1734-1818).  With 
investigation  (anatomic  and  physiologic),  and  lapse  of  time,  views  changed. 
especially  among  the  French,  English  and  Germans.  Definite  records  of 
dissection  and  observation  on  the  nerves  of  the  tractus  genitalis  (uterus) 
begin  to  accumulate  in  literature. 

Eustachius,  an  Italian  anatomist  of  Eustachian  tube  fame,  published  at 
Amsterdam  in  1722  Tabula  Anatomica.  Eustachius  described  the  nerves 
connecting  the  lumbar  ganglia  with  the  hypogastric  plexus,  which  in  union 
with  branches  from  the  sacral  nerves  arrived  at  the  side  of  the  uterus. 

Reignier  de  Graaf,  a  Dutch  anatomist  of  Graffian  follicle  fame,  published 
at  Amsterdam  in  1705  "Opera  Omnia."  He  dissected  and  pursued  the  nerves 
to  the  uterus,  ovary,  oviduct  and  ligamentum  latum.  The  presentations  are 
schematic  and  description  crude. 

Thomas  Willis,  an  English  anatomist  and  philosopher  of  Circle  of  Willis 
fame,  published  at  Geneva  in  1680  "Cerebri  Nervorumque  Descriptio." 
Willis  first  described  the  course  of  the  ovarian  nerves,  though  defectively. 
He  styled  the  solar  plexus,  cerebrum  abdominale. 

Albert  Haller,  a  Swiss  anatomist  of  multiple  eponymic  fame,  published 
at  Lausanne  in  1778  Elementa  Physiologiae.  He  limited  the  origin  of  the 
ovarian  nerves  to  the  plexus  renales  and  lateral  sympathetic  chain  only. 
This  error  was  repeated  by  Tiedemann  in  his  1822  publication.  He  left  no 
illustration. 

R.  Vieussens  (1641-1716),  a  French  anatomist  of  multiple  eponymic 
fame  (the  ganglion  of  Vieussens — solar  plexus),  left  a  rough  presentation  of 
the  sympathetic. 

Johann  Gottlieb  Walter,  a  German  anatomist  of  "coccygeal  ganglion" 
fame,  published  at  Berlin  in  1783  talnilcc  ncrv.  Thoracis  ct  Abdominis.  He 
presents  several  excellent  copper-plate  tables  of  the  thoracic  and  abdominal 
nerves,  which  have  become  famous  for  accurateness  and  careful  preparation. 
To  1875  Walter's  tables  were  the  best  presentation  of  the  sympathetic, 
especially  the  best  and  most  accurate  in  their  presentation  of  the  sympathetic 
nerves  supplying  the  female  tractus  genitalis.  Walter's  tables  are  not 
schematic  but  naturally  correct,   excelling  the  later   much-lauded  tables  of 


DEVELOPMENTAL  KNOWLEDGE  OF  SYMPATHETIC  NERVES  23 

Tudemann  (1S22).  It  is  the  first  presentation  of  the  tractus  genitalis  in  its 
natural  position  and  in  connection  with  the  pelvic  and  abdominal  viscera. 
Unfortunately  the  plexus  aorticus  and  especially  the  plexus  hypogastrics  is 
incompletely  presented.  Also  the  course  of  the  nerves  in  the  uterus  and 
ovary  is  not  indicated.  Walter  was  the  first  who  presented  a  ganglion  on 
the  lateral  borders  of  the  cervix  uteri.  Hence  these  nerve  masses  or  nodes 
should  be  known  by  the  eponym  "Walter's  cervico-uterine  ganglion." 
Walter's  plates  of  the  sympathetic  are  superior  to  those  of  Tiedemann  but 
are  not  so  well  known.     It  is  a  rare  book. 

William  Hunter  (171^-1783),  the  celebrated  English  obstetrician,  pub- 
lished an  atlas  on  the  nerves  of  the  pregnant  human  uterus  which  is  a  note- 
worthy work.  I  could  find  no  presentation  of  the  uterine  nerves  originating 
from  the  sacral  nerves  in  the  atlas.  Hunter  asserted  that  the  uterine  nerves 
all  rise  from  the  intercostal,  that  they  assume  the  same  course  as  the  blood- 
vessels and  that  therefore  on  each  side  will  occur  a  plexus  spermaticus  and 
plexus  hypogastrics  A  plexus  springs  from  the  ganglion  semilunare  and 
while  it  passes  to  uterus  is  strengthened  by  branches  from  the  intercostals. 
The  plexus  aorticus  emits  nerves  to  the  plexus  renalis,  which  gives  origin  to 
the  plexus  spermaticus.  The  plexus  aorticus  divides  into  two  nervi  hypogas- 
tric!, distal  to  the  aortic  bifurcation.  Each  hypogastric  nerve  divides  into 
a  dorsal  branch  supplying  the  rectum  and  a  ventral  branch  which  follows 
the  arteria  uterina  to  supply  the  uterus.  The  greatest  number  of  nerve 
branches  tend  toward  the  cervix  uteri,  according  to  Hunter.  He  believed 
that  the  uterine  nerves  increased  in  dimension  during  gestation,  furnishing 
no  proof  by  specimen  however. 

John  Hunter  (1728-1793),  the  famous  brother  of  William  Hunter,  asserted 
that  its  nerves  did  not  increase  in  dimension  during  gestation,  also  adding 
no  proof  by  specimen.  William  Hunter  shows  sympathetic  nerves  supplying 
the  cervix,  corpus  and  fundus  uteri.  Previously  and  subsequently  to 
Hunter's  time  it  was  a  widespread  dogma  that  the  sympathetic  nerve 
supplied  corpus  and  fundus  uteri  only — not  the  cervix  uteri. 

Johann  Friedrich  Osiander  (son,  1787-1855),  obstetrician  at  Gottingen, 
published  a  prize  essay  in  1808  on  Nerves  of  the  Uterus,  noting  that  he 
believed  that  nerves  were  present  in  the  uterus  but  could  not  detect  them. 

Friedrich  Benjamin  Osiander  (father,  1759-1822),  obstetrician  at 
Gottingen,  inventor  of  uterine  traction  forceps,  asserted  in  his  Handbook  of 
Obstetrics,  1818,  that  he  doubted  if  any  man  had  seen  nerves  in  the  uterus. 

Friedricus  Tiedemann  (1781-1861),  German  professor  of  anatomy  in 
Heidelberg  from  1816  to  1844,  published  in  Heidelberg  in  1822  Tabulae 
Nervorum  Uteri,  which  has  become  extensively  and  favorably  known,  many 
times  copied,  and  prized  as  the  best  presentation  of  the  nerves  of  the  uterus 
in  connection  and  with  the  natural  position  of  the  viscera.  Tiedemann's 
plates  are  schematic,  defective  and  inferior  to  those  of  Walter — his  predeces- 
sor by  thirty-seven  years.  Tiedemann's  plates,  like  Walter's  and  Hunter's, 
are  the  most  imperfect  in  presenting  the  relations  of  the  sacral  nerves  to 
the  hypogastric  plexus  and  uterus.  Tiedemann  advocated  that  the  nerves 
of  the  uterus  were  enlarged  during  gestation  and  atrophied  during  senescence. 


24  THE  ABDOMINAL  AND  PELVIC  BRAIN 

J.  G.  C.  F.  M.  Lobstein  (1777-1815),  a  French  anatomist  and  obstetrician 
at  Strassburg  published  at  Paris  in  1823  nervi  sympatJictici  Humani  Fabrici, 
etc.  Lobstein  accentuated  the  plexus  mesentericus  superior  and  inferior. 
He  practically  denied  the  existence  of  the  plexus  spermaticus. 

My  observation  of  Lobstein's  book  on  the  sympathetic  induces  me  to 
think  that  he  obscured  and  retarded  its  knowledge  rather  than  advanced  it. 
For  fifty  years,  to  1875,  no  special  work  appeared  on  the  nerves  of  the 
tractus  of  the  female.  The  general  assertion  for  half  a  century,  on  whose 
authority  I  know  not,  was  that  the  sacral  nerves  supplied  the  cervix  and 
the  sympathetic  the  body  and  fundus.  In  1839,  in  an  atlas  to  the  book  of 
Frances  Joseph  Moreau  (1789-1862)  entitled  Traite  pratique  des  accoucJiemans, 
appeared  a  new  illustration  of  the  nerves  of  the  pregnant  uterus  after  J.  M. 
Jacquemier  (1806-1879).  It  is  schematic,  defective,  imitates  Tiedemann's 
plates  and  their  errors  and  adds  practically  nothing  new. 

From  1838  to  1846  occurred  the  fierce  polemic  on  the  nerves  of  the 
uterus  between  Robert  Lee  and  Snow  Beck,  chiefly  found  in  the  Philosophi- 
cal Transactions.  Robert  Lee  (1793-1877),  an  English  obstetrician,  physician 
to  the  British  Lying-in  Hospital,  published  several  papers  on  the  nerves  of 
the  uterus  from  1838  to  1846.  Lee  claimed  to  find  under  the  perimetrium 
several  nerve  plexuses  which  were  connected  with  the  ovarian  and  hypogas- 
tric plexuses  as  well  as  the  sacral  nerves.  Since  Lee  produced  no  convincing 
evidence,  no  microscopic  demonstration  as  regards  the  cellular  structure  of 
the  claimed  nervous  ganglia,  suspicion  arose  among  his  colleagues  (especially 
Snow  Beck)  that  he  had  mistaken  elastic  fibres,  connective  or  muscular 
tissue  of  the  uterus  for  nerve  plexuses.  Lee  was  an  Englishman  of  typical 
vigor,  possessing  the  spirit  of  progress  and  was  not  easily  turned  aside  by 
adverse  criticism  of  opposing  colleagues.  He  said  the  processes  which  he 
had  held  for  nerves  branched  with  the  arteries  of  the  uterus,  a  fact  which, 
according  to  Lee,  occurred  nowhere  with  elastic  or  muscular  tissue.  By  an 
industrious  prosecution  of  his  dissecting  labors  he  rediscovered  in  1841, 
Walter's  cervico-uterine  ganglion  (of  1783)  and  proved  it  a  constant  structure. 

Lee's  Monograph,  the  anatomy  of  the  nerves  of  the  uterus,  1841,  lies 
before  me.  It  is  an  excellent  labor  by  an  earnest  investigator.  It  contains 
two  plates  some  10x10  inches  illustrating  the  dissected  nerves  and  ganglia 
of  two  pregnant  uteri,  one  in  the  sixth  and  the  other  in  the  ninth  months  of 
gestation.  Lee  said,  in  short,  that  his  dissections  prove  that  the  uterus 
possesses  a  great  system  of  nerves,  that  they  enlarge  with  gestation  and 
return  to  the  original  condition  subsequent  to  parturition. 

Also,  if  the  nerves  of  the  uterus  could  not  be  demonstrated  to  exist,  its 
physiology  and  pathology  would  be  completely  inexplicable.  Lee  repeatedly 
demonstrated  the  cervico-uterine  ganglion  in  the  pregnant  and  non-pregnant 
uterus.  He  showed  that  the  plexus  hypogastrics  ended  in  the  great  cervico- 
uterine  ganglion,  which  he  claimed  was  composed  of  six  or  seven  smaller 
unifed  by  nerve  strands  and  located  on  the  lateral  border  of  the  cervix  uteri. 
He  noted  that  the  branches  of  the  second  and  third  sacral  nerves  entered  the 
cervical  ganglion.     Lee  located  a  ganglion  at  the  junction  of  the  uterus  and 


DEVELOPMENTAL  KNOWLEDGE  OE  SYMPATHETIC  NERVES    25 

the  oviduct.  He  also  located  a  subperitoneal  ganglion  on  the  dorsum  of  the 
corpus  uteri  and  one  on  the  ventrum  of  the  corpus  uteri  of  the  extensive 
surface  dimension.  These  subperitoneal  ganglia,  according  to  Lee's  illus- 
trations, extend  over  large  surface  areas  of  the  corpus  uteri  and  stand  in 
connection  with  the  hypogastric  plexus  and  cervico-uterine  ganglion. 

Modern  investigations,  especially  by  the  aid  of  the  microscope,  demon- 
strate that  Lee's  extensive  subperitoneal  ganglion  do  not  exist.  Later  in 
Lee's  dissecting  labors  he  had  Dalrymple  make  microscopic  sections  of  the 
nerve  plexuses  which  confirmed  their  nervous  structure,  but  no  mention  is 
made  of  a  microscopic  examination  to  confirm  the  nervous  structure  of  the 
uterine  ganglia.  Robert  Lee  located  three  vesical  ganglia,  viz:  (a),  external 
vesical  ganglia;  (b),  middle  and  (c),  external  vesical  ganglia.  Later  he 
described  but  two  internal  and  external  vesical  ganglia.  Dr.  Robert  Lee  made 
valuable  additions  to  the  literature  of  the  nerves  of  the  uterus.  His  labors 
aroused  vigorous  opponents  and  valuable  polemics  by  which  was  instigated 
extensive  additional  researches.  He  rediscovered  Walter's  cervico-uterine 
ganglion,  hence,  the  memory  of  this  earnest  investigation  should  be  entitled 
to  the  eponym,  "Lee's  cervico-uterine  ganglion." 

T.  Snow  Beck,  an  English  anatomist,  published  in  1846  in  the  Philo- 
sophical Transactions,  several  investigations  concerning  the  nerves  of  the 
uterus,  which  were  almost  a  complete  negation  of  Lee's  views.  Snow  Beck 
claimed  that  Lee's  cervico-uterine  ganglion  was  merely  a  mass  of  connective 
tissue  containing  a  few  small  ganglion  cells,  that  it  was  due  to  the  union  of 
the  branches  of  the  sacral  nerves  and  hypogastric  plexus.  He  similarly 
disposed  of  Lee's  other  uterine  ganglia.  Snow  Beck  gave  detailed  descrip- 
tions of  the  uterine  nerves,  adding  some  illustrations  which  contain 
numerous  errors.  He,  like  Lee,  had  prepared  the  specimens  on  the  extir- 
pated genitals — not  while  they  were  in  situ.  This  insured  confusion  in 
non-accuracy  and  supposed  schematism. 

In  1894  I  advocated  that  the  ganglionated  mass  located  at  the  lateral 
border  of  the  uterus  should  be  termed  the  pelvic  brain  (cerebrium  pelvicum). 

T.  Snow  Beck  introduced  the  term  pelvic  plexus,  which  is  the  result  of 
the  union  of  the  branches  of  the  sacral  nerves  second,  third  and  fourth  with 
the  distal  end  of  the  hypogastric  plexus.  Secondary  to  Snow  Beck  the 
second  sacral  nerve  sends  one  branch  to  the  pelvic  plexus,  the  third  sends 
12  or  13,  the  fourth,  5  or  6.  Small  ganglia  are  distributed  over  the  pelvic 
plexus,  which  sends  nerves  to  the  bladder,  vagina  (10  to  12)  and  rectum  but 
not  to  the  uterus.  T.  Snow  Beck  indicates  that  many  of  the  uterine  nerves 
are  very  fine,  threadlike  and  without  plexiform  character.  T.  Snow  Beck's 
illustrations  are  obscure,  the  descriptions  contradictory,  and  doubtless 
prepared  after  being  extirpated  from  the  body,  which  increased  the  errors. 
He  denied  the  claim  of  Robert  Lee  that  the  uterine  nerves  enlarged  in 
dimensions  during  gestation.  T.  Snow  Beck's  iconoclastic  negation  of 
Lee's  conclusions  in  regard  to  the  nerves  and  ganglia  of  the  female  genitals 
served  rather  as  a  sample  of  medical  polemic  of  those  times  than  to  enhance 
knowledge.     The  work  of  Clay,  1845,  and  that  of  Swann,  1846,  The  Physiol- 


26  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

ogy  of  the  Nerves  of  the  Uterus,  were  not  to  me  accessible,  but  since  I  find 
nowhere  citations  from  them  perhaps  they  contain  nothing  new. 

Antoine  Joseph  Jobert  (de  Lamballe)  (1799-1867),  a  French  anatomist 
and  surgeon,  published  in  1841  in  Comptes  Rendus  de  Science  de  V  Academic, 
T  XII,  No.  20,  his  Researches  stir  la  Disposition  dcs  Nerfs  de  V  uteres.  His 
illustrations  are  faulty  and  his  work  adds  little  new  data.  Jobert  announces 
that  no  nerves  penetrate  the  portia  vaginalis  uteri. 

Ludwig  Moritz  Hirschfield  (1804-1876),  professor  of  anatomy  at  Paris 
and  Warsaw,  and  Jean  Baptiste  Francoise,  Leville  (1769-1829),  French 
anatomist,  published  in  1853  Neurologic  des  Cript  et  Icongraphic  du  System 
Nerveaux.  The  same  illustrations  are  employed  in  the  Atlas  of  Savage, 
1863.  The  illustrations  are  not  clear  and  visceral  positions  with  nerve 
relations  are  incorrect. 

Ferdinand  Frankenhauser  (died  1894),  a  German  obstetrician,  published 
at  Jena  in  1867  Die  nerven  der  Gebaermntter.  This  book  is  excellent, 
accurate,  comprehensive,  unique  and  instructive.  Though  a  book  of  82  pages 
only,  it  is  a  monument  of  industry  for  all  time.  His  descriptions  are 
accurate,  his  illustrations  are  according  to  Nature.  I  am  indebted  to  Dr. 
Frankenhauser  for  his  labors  in  the  sympathetic  nerves,  especially  those  of 
the  tractus  genitalis.  His  honor  is  admirable  in  crediting  justly  to  every 
author  his  share  in  the  developmental  knowledge  of  the  sympathetic  nerves. 
Other  authors  have  labored  in  the  microscopical  field  of  the  sympathetic 
nerve  but  space  forbids  further  mention. 

(B.)     Microscopic. 

Reliable  microscopical  examinations  of  the  nerves  of  the  tractus  genitalis 
are  limited  in  number  and  separated  by  long  intervals.  Microscopic  anatomy 
began  about  1850.  W.  M.  Hunter  (1805),  Robert  Lee  (1846)  and  Fr. 
Tiedemann  (1822)  claimed  that  the  uterine  nerves  increased  in  dimension 
during  gestation.  John  Hunter,  the  brother  of  William  Hunter,  denied 
that  the  nerves  enlarge  during  gestation,  that  the  thickening  was  due  to 
multiplication  of  the  connective  tissue. 

Herman  Friedrich  Kilian  (1800-1863),  a  German  obstetrician,  published 
in  1851  in  the  ZeitscJirifi  fur  rationclle  mcdicin,  a  work  Die  Nerven  des 
Uterus,  which  founded  for  all  time  the  microscopic  structure  of  the  uterine 
nerves.  Kilian  attempted  to  determine  which  part  of  the  uterus  was  sup- 
plied by  sympathetic  and  which  by  spinal  nerves  by  the  aid  of  the  micro- 
scope. He  claimed  that  both  sympathetic  and  spinal  nerves  supplied  all 
parts  of  the  uterus,  but  sympathetic  nerves  only  were  found  in  ovarian 
plexuses.  He  claimed  that  the  cervix  is  richer  in  nerves  than  the  body. 
Ganglion  cells  lie  nowhere  in  the  uterus.  Kilian  announced  an  age 
relation  of  uterine  nerves.  During  pueritas  the  nerves  were  limited  in 
number  and  dimension.  During  adolescence  the  number  increased.  During 
gestation  the  number  and  dimension  were  marked.  During  senescence  the 
nerves  became  lessened  in  number  and  dimension.  Kilian  concerned  himself 
with:  (a)  the  origin  of  the  uterine  nerves;  (b)  the  changes  experienced  by  a 


DEVELOPMENTAL  KNOWLEDGE  OF  SYMPATHETIC  NERVES    27 

nerve  passing  through  the  uterus;  (c)  the  age  relations.  Frankenhauser  of 
Jena  in  lsiU,  Koerner  of  Breslau  in  1864,  Kehrer  of  Giessen  in  1864,  Polle 
of  Gottingen  in  1805,  Frey,  1867,  and  Kolliker  (1817 — living)  and  Koch  (1843 — 
living,)  in  1865  published  accounts  of  ganglia  on  the  uterine  nerves  (in 
addition  to  the  cervico-uterine  ganglion).  To  18(37  little  was  added  to  the 
great  work  of  Kilian  except  ganglia  on  the  uterine  nerves  and  special  nerve 
ending  in  the  uterus. 

We  have  thus  finished  a  very  limited  and  meager  sketch  of  the  sympa- 
thetic nerve.  Vast  numbers  of  worthy  names  and  workers  have  not  been 
mentioned  for  want  of  space.  However,  a  few  of  the  landmarks  in  the 
development  of  the  knowledge  of  the  sympathetic  nerves  have  been  noted, 
from  Galen,  its  discoverer,  to  the  present  time.  The  sympathetic  nerve  has 
long  been  an  unknown  field  as  to  facts.  Our  knowledge  of  the  nerve  is  still 
incomplete  and  will  be  for  some  time  to  come. 

To  the  scholar  and  investigator  the  steps  by  which  knowledge  is  gained 
are  not  only  interesting  but  of  value  for  further  progress. 


CHAPTER    II. 

A    CLASSIFICATION    OF    DISEASES    WHICH    MAY    BELONG    IN 
THE  DOMAIN  OF  THE  SYMPATHETIC  NERVES. 

The  sympathetic  nerve  concerns  itself  with  the  life  of  the  viscera.     It  presides 
■■■  the  visceral  economy. 

"A  man's   poller  is   hedged   in   by  necessity,  which,  by  mat  ments,  he 

touches  on  every  side,  until  he  learns  its  art." 

— Ralph   Waldo  Emerson. 

We  here  present  the  classification  of  diseases  considered  to  belong  to 
the  domain  of  the  sympathetic  nerve  by  various  writers.  The  classification 
has  no  hard  or  fast  lines,  but  we  present  it  for  the  purpose  of  securing  a 
general  or  bird's-eye  view  of  the  field  of  the  sympathetic.  The  field  of  definite 
action,  physiologic,  anatomic  or  pathologic,  of  the  cerebrospinal  and 
sympathetic  nerves,  is  not  yet  settled.  The  pathology  of  the  sympathetic 
must  rest  on  its  physiologic  paths.  Physiology,  with  our  present  limited 
anatomical  means  of  tracing  nerve  fibers,  is  surer  than  anatomy.  It  is 
difficult  to  make  a  satisfactory  classification  of  diseases  of  the  sympathetic, 
for  a  multitude  of  symptoms,  which  may  reasonably  be  supposed  to  depend 
upon  the  sympathetic  nerves,  are  encountered  without  our  being  able,  by 
minute  examination,  to  recognize  the  morbid  process  upon  which  they 
depend.  Their  chief  manifestation  is  through  reflex  action,  referred 
disturbance. 

Again,  many  sympathetic  nerves,  and  especially  ganglia,  are  found  at 
the  autopsy  sclerosed,  pigmented  or  possessed  of  increased  connective  tissue, 
yet  the  patient  left  no  records  of  physical  complaints  during  life.  Hence,  it 
is  difficult  to  retrace,  in  such  cases,  the  interpretations  of  Nature's  physio- 
logic experiment.  Also,  one  is  not  always  able  to  decide  whether  the 
pathologic  findings  at  the  autopsy  are  not  secondary.  No  doubt  there  is  a 
special  pathology  of  the  sympathetic  nerve,  or  rather  ganglia;  but  it  may 
not  be  a  recognized  pathology.  In  normal  and  pathological  states  the 
sympathetic  nerve  is  constantly  affected  by  reflex  irritations.  The  pathology 
of  the  sympathetic  is  chiefly  observed  in  the  cervical  and  abdominal  ganglia, 
and  is  characterized  by  vascularity,  deposit  of  excessive  connective  tissue, 
pigmentation,  atrophy,  hypertrophy,  sclerosis,  fatty  infiltration,  accumu- 
lation of  microbes  and  leucocytes  in  the  ganglia,  amyloid  or  fatty  degenera- 
tion. Sometimes  the  blood-vessels  of  the  ganglia  are  found  dilated  and 
engorged  with  white  blood  corpuscles. 

Classification  of  diseases  which  are  certainly,  or   probably,    connected 
with  the  sympathetic  nervous  system  : 
1.   Functional  disturbances: 

(a)  Irritation  (hyperesthesia). 

(b)  Paralysis  (anesthesia). 

28 


hkMm 

r:-rt 

n&       i  kc, 


Wr 


It 


mm 

rail 


d&i 


m 


m 


AN  ILLUSTRATION  OF  THE  ABDOMINAL  SYMPATHETIC  NERVE  OF 

THE  MALE 

Fig.  2.     It  is  accompanied  by  ureteral  dilatation. 

Drawn  from  a  specimen  under  alcohol  which  I  secured  at  an  autopsy  through  the 
courtesv  of  Dr.  W.  A.  Evans  and  Dr.  C.  O'  Byrne.  1  and  2,  abdominal  brain ;  1"  and  12 
represent  the  spermatic  ganglia  emitting  their  plexuses  along  the  spermatic  artery;  H 
represents  the  coalesced  hypogastric  ganglia.  11.  inferior  mesenteric  ganglia.  Note  the 
network  of  nerves  ensheathingthe  ureters  and  also  the  anastomosis  of  the  plexus  spermaticus 
with  the  plexus  ureteris.  hence,  the  testicular  pain  is  explained  in  ureteral  calculus.  Observe 
the  numerous  and  marked  dimensions  of  the  ganglia  renalia. 


30  THE  aBDOMIXAL  AXD  PELVIC  BRAIX 

2.  Hyperesthesia  of  the  sympathetic  (reflex  irritation) : 

(a;  The  abdominal  brain  (neuralgia  celiaca). 

(b)  The  mesenteric  plexus  (enteralgia,  enterodynia,  colic). 

(c)  Hypogastric  plexus  (neuralgia  hypogastrica). 

(d)  Gastric  plexus  (gastralgia,  gastrodynia). 

(e)  Spermatic  or  ovarian  plexus  (ovarian  neuralgia). 

(f)  Splenic  plexus  (splenic  neuralgia). 

(g)  Hepatic  plexus  (hepatic  neuralgia), 
(h)  Renal  plexus  (nephralgia). 

(i)    Pelvic    brain     or    cervico-uterine    ganglia    (irritable    uterus, 

uterine  neuralgia), 
(j)    Aortic  plexus. 
(k)  Diaphragmatic  plexus. 
(1)    The  cervical  ganglia. 

(m)  The  cardiac  ganglia  fcardialgia,  angina  pectoris). 
(n)  Trigeminus  (facial  neuralgia). 

3.  Anesthesia  of  the  sympathetic. 

4.  Paralysis  or  spasmodic  affections  of  voluntary  muscles: 

(a)  Locomotor  ataxia. 

(b)  Epilepsy. 

(c)  Diphtheritic  paralysis. 

5.  Progressive  muscular  atrophy  : 

(a)  Pseudo-muscular  atrophy. 

(b)  Progressive  facial  hemiatrophy. 

6.  Visceral  neuroses: 

(a)  Hysteria. 

(b)  Gastralgia. 

(c)  Gastrodynia. 

(d)  Insomnia. 

(e)  Pleurodynia. 

(f)  Peritonismus. 

(g)  Mastodynia. 

7.  Neurasthenia. 

8.  Pigmentation: 

(a)  Spleen. 

(b)  Liver. 

(c)  Uterus. 

(d)  Adrenals. 

9.  Addison's  disease  (bronzed  skin), 

10.  Hemicrania  (.headache). 

11.  Trigeminal  neuralgia  (facial  neuralgia). 

12.  Exophthalmic  goiter,   Pavy's  (1825),   Graves'   (1635),  or   Basedow's 

-  10)  disease. 

13.  Angina  pectoris  or  stenocardia  (Heberden's  disease  (1768). 

14.  Diabetes  mellitus  ^hepatic  neuralgia). 

15.  Diabetes  insipidus  (renal  neuralgia). 


DISEASES  IX  DOM, II X   OF   SYMPATHETIC   NERVES  31 

16.  Unilateral  hyperidrosis  (sweating). 

17.  Edema. 

L8.   Diarrhea. 

19.  Glaucoma. 

20.  Myxedema  (sterodema). 

21.  Symmetrical  gangrene  of  the  extremities. 

22.  Pathologic  changes  in  the  sympathetic  in  other  diseases: 

(a)  In  syphilis. 

(b)  In  old  age. 

(c)  Leukemia. 

(d)  Sunstroke. 

(e)  Infectious  diseases. 

(f)  Cardiac  diseases. 

(g)  Malignant  diseases, 
(h)  Pigmentation. 

23.  Splanchnoptosia. 

The  above  table  records  diseases  which  are  certainly  or  probably 
connected  with  the  sympathetic  nervous  system.  However,  some  of  them 
ere  much  more  doubtfully  connected  than  others. 

We  will  here  consider  briefly  the  hyperesthesias  (neuralgias)  of  the 
abdominal  brain  and  its  closely  related  plexuses  of  nerves.  In  regard  to 
the  functional  disturbances,  or  reflex  irritation,  we  have  hyperesthesia  or 
exalted  irritability  of  the  sensory  nerves.  The  hyperesthetic  nerve  manifests 
itself  first  by  pain,  secondly  by  a  reflex  act  on  a  motor  apparatus.  Hyperes- 
thesia, or  exalted  irritability  of  the  sympathetic  nerves,  is  liable  to  manifest 
pain  irregularity,  periodically,  paroxysmally,  and  yet  retain  some  irritability 
during  the  intervals.  The  symptoms  of  hyperesthesia  are  generally  uniform 
and  persistent  throughout  the  duration  of  the  disease.  Early  life  is  very  free 
from  hyperesthesia  of  nerves  and  it  does  not  endanger  life.  Anatomically, 
we  know  little  of  the  characteristic  changes  in  structure  in  hyperesthesia. 
The  etiology  of  hyperesthesia  is  obscure;  however,  malnutrition  is  perhaps  a 
bottom  factor.  The  presence  of  certain  substances,  such  as  lead,  will  induce 
hyperesthesia  or  lead  colic  (neuralgia  saturnina).  Climate,  sex  and  age 
play  a  role,  as  does  anemia  or  plethora.  Checking  of  secretions  induces 
hyperesthesia,  as  does  rheumatism  or  congestion.  Hyperesthesia  generally 
runs  a  chronic  course,  is  periodic,  is  seldom  completely  recovered  from,  is 
often  a  forerunner  of  organic  disease,  is  very  persistent  individually,  and  is 
doubtless  accompanied  by  tonic  spasm  of  vessels. 

Hyperesthesia  of  the  nerves  of  special  sense  is  manifested  by  phantasms. 
One  of  the  objects  of  this  little  volume  is  to  attempt  to  show  anatomically 
and  physiologically  how  reflex  irritation  in  one  diseased  viscus  will  unbalance 
the  rest.  For  example,  what  gynecologist  has  not  personally  observed  that  a 
tender,  irritable  uterus  will  unbalance  the  other  viscera  (abdominal  and 
thoracic)  year  after  year.  From  some  form  of  malnutrition  or  other  morbid 
process  the  uterus  has  become  chronically  hyperesthetic,  and  the  result  is 
that  the  secretions  and    excretions,    visceral    rhythm    and    circulation,   are 


32  THE  ABDOMINAL  AND  PELVIC  BRAIN 

disturbed,  while  malnutrition  results  with  an  accompanying  neuroses,  which 
is  due  to  the  nerve  apparatus  being  bathed  in  waste-laden  blood. 

It  is  not  easy,  practical  or  even  useful  to  discriminate  between  hyperes- 
thesia and  a  visceral  neurosis,  as  one  may  blend  into  and  become  identical 
with  the  other.  The  active  hyperesthesias  of  the  great  ganglia  of  the 
sympathetic  system  are  characterized  by  an  overpowering  sense  of  prostra- 
tion, a  sense  of  impending  dissolution,  as  if  the  center  of  life  itself  would  be 
destroyed.  This  is  the  essential  and  common  story  of  neurotic  women.  A 
blow  on  the  pit  of  the  stomach  makes  one  stand  with  overwhelming  awe  of 
a  coming  danger,  a  sense  of  death-like  anxiety  and  annihilation.  These 
profound  impressive  sensations  are  characteristic  of  the  sympathetic  nerve. 
He  who  has  once  fainted  need  not  be  told  of  profound  sensations.  It  may 
be  stated  here  that  the  indefiniteness  of  the  symptoms  and  findings  in  the 
sympathetic  tracts  have  induced  theoretical  writers  to  offer  placebos  to  the 
profession  in  the  form  of  a  profusion  of  terms,  such  as  gastralgia,  gastrodynia, 
gastric  neuroses,  and  gastric  neuralgia,  terms  some  of  which  mean  nothing 
to  the  diagnostician,  and  are  confusing  to  physicians. 

From  a  careful  study  of  visceral  neuralgia  it  is  evident  that  it  is  a  second- 
ary disease.  It  consists  of  a  peculiar  malnutrition  of  a  sensitive  nerve 
apparatus.  The  treatment  of  visceral  neuralgia  consists  in  improving  nutri- 
tion, relieving  present  distress  by  harmless  means  and  removing  all  depressing 
causes.  The  cause  producing  the  reflex  irritation  of  different  viscera  must 
be  discovered  and  the  appropriate  remedial  agent  employed. 


CHAPTER   III. 

APPLIED    ANATOMY    AND    PHYSIOLOGY    OF   THE    ABDOMINAL 
VASOMOTOR    NERVE   (NERVUS    VASOMOTORIUS). 

A  complete  nervous  apparatus  consists  of  nerve  or  ganglion  cell  (c.  g.  cerebrum), 
a  conducting  cord  (e.  g.  spinal  cord,  peripheral  nerve),  a  periphery  (e.  g. 
Touch  corpuscle). 

"Defeated  o'er  and  o'er  but  ne'er  disgraces."— From  the  London  Times  and  placed 
on  a  monument  to  Lord  Bcaconsfield. 

The  sympathetic  system  of  nerves  (nervus  vasomotorius)  has  experi- 
enced a  variety  of  names.  Synonyms:  The  vasomotor  nerve  (nervus 
vasomotorius)  (Benedict  Stilling,  1840 — German  anatomist  and  surgeon, 
1810-1879).  The  sympathetic  nervous  system  (systema  nervorum  sympath- 
icum).  The  vegetative  nervous  system  (systema  nervorum  vegetatorum). 
The  ganglionic  nervous  system  (systema  nervorum  ganglionicum).  The 
nervous  system  of  organic  life  (systema  nervorum  vitse  organicae.)  The 
nerve  system  of  nutritive  life  (systema  nervorum  vitas  nutritiae).  The  great 
sympathetic  nerve  (nervus  sympathicus  magnus).  The  intercostal  nerves 
(nervus  intercostalis,  Thomas  Willis,  1622-1674,  English  anatomist).  The 
great  intercostal  nerve  (nervus  intercostalis  magnus).  The  trisplanchnic 
nerve  (nervus  trisplanchnicus,  Francois  Chaussier,  1746-1828,  French 
anatomist).  The  ganglionic  nerves  (nervus  gangliosus).  The  visceral 
nervous  system  (systema  nervorum  visceralis).  The  trunk  nervous  system 
(systema  nervorum  trunci)  (Rumpf  nerven  system,  K.  F.  Burdach,  German 
anatomist,  1776-1847).  Grand  sympathetic.  Since  this  system  of  nerves 
rules  the  motion  of  the  heart  and  blood-vessels  I  shall  assume  with  Stilling 
that  the  most  appropriate  term  is  the  vasomotor  nerve  (nervus  vasomo- 
torius). The  term  "sympathetic"  nerve  is  without  signification  and  hence 
should  be  discarded  for  a  term  significant  of  function;  therefore,  nervus 
vasomotorius,  since  the  blood  carries  nutrition  to  all  organs,  the  term"nerves 
of  nutritive  life"  is  included  in  the  term  nervus  vasomotorius. 

The  Vasomotor  Nerve 

(nervus  vasomotorius)  or  unfortunately  the  meaningless  term  sympathetic 
nerve  consists  of:  I,  nerve  ganglia,  II,  nerve  cords,  III,  nerve  plexuses. 
I.  The  nerve  ganglia,  for  practical  purposes,  present  three  grand 
divisions,  viz. :  (1)  the  bilateral  chain  of  trunk  ganglia  (trunci  nervi  sympath- 
ici)  extending  from  the  base  of  the  skull  (ganglion  of  Francois  Ribes, 
1800-1864— French  professor  of  hygiene  in  Mont  Pieler)  to  the  distal  end 
of  the  coccyx  or  coccygeal  ganglion.  (2)  Three  great  ganglionated  plexuses 
or  aggregations  of  ganglia  known  as  {prevertebral  plexuses)  the  prevertebral 
plexuses  of  the  thorax,  abdomen  and  pelvis.      (3)  Automatic  visceral  ganglia 

3  33 


34 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


or  peripheral  ganglia  located  in  relation  with  the  thoracic,  abdominal  and 
pelvic  viscera.  The  ganglia  composed  of  nerve  cells  receive,  reorganize 
and  emit  nerve  forces.  II.  {Afferent  and  efferent  apparatus.}  The  nerve 
cords  composed  of  nerve  fibers  consist  of  conducting,  communicating  or 
distributing  apparatus.  III.  The  vasomotor  nerve  possesses  peculiar 
ganglionated  plexuses  and  nonganglionated  plexuses.  The  vasomotor  nerve 
is  connected  to  the  spinal  cord  through  the  (a)  rami  communicantes;  (b) 
nervi  sacralia  and  (c)  to  the  cerebrum  by  the  vagi. 


Fig.  3.  A  diagram  of  the  nervus  vasomotorius  (sympathetic)  from  the  proximal  end 
(ganglion  of  Ribes)  to  the  distal  end  (coccygeal  ganglion  of  Luschka)  presenting  a  lateral  view 
of  the  truncus  vasomotorius  (lateral  chain)  and  the  three  prevertebral  ganglia  (cardiac, 
coeliac  and  pelvic  plexuses).  Observe  the  exit  of  the  three  cardiac  nerves,  the  three  abdom- 
inal splanchnics  and  the  3  (or  more)  pelvic  splanchnics  (after  Flower). 

GENERAL   VIEW   OF   THE   VASOMOTOR    SYSTEM. 

The  vasomotor  nerves  or  nervus  vasomotorius  originate  in  the  cere- 
brospinal. The  bilateral  halves  of  the  vasomotor  nerves  (sympathetic) 
anastomose  at  the  proximal  and  distal  ends  in  the  medium  plexuses, 
especially  through  the  cardiac  plexus,  the  abdominal  brain  and  pelvic  brain, 
thus  solidly  and  compactly  anastomosing,  connecting  all  viscera  into  a 
balanced  system.  The  vasomotor  or  sympathetic  nerves  are  practically  the 
visceral  branches  of  the  spinal  nerves.  At  the  origin  of  the  visceral  vessels 
from  the  aorta,  vasomotor  ganglia  as  a  rule  exist  according  in  size  with  that 
of  the  vessel,  e.  g.,  at  the  origin  of  the  aorta  from  the  heart  is  located  the 


ABDOMINAL  VASOMOTOR  NERVE 


35 


cardiac  ganglia  or  plexus  of  Wrisberg  (German  anatomist  [1739-1808],  professor 
at  Gottingen).  At  the  origin  of  the  coeliac  axis  is  located  the  abdominal 
brain.  At  the  origin  of  the  common  iliacs  originally  existed  the  pelvic  brain. 
As  a  rule  large  vasomotor  or  sympathetic  ganglia  are  located  at  the  origin 
of  large  visceral  vessels  from  the  aorta. 


Fig.  4  (Jacob  Henle,  1809—1885).  Represents  the  abdominal  brain,  the  lumbar  lateral 
chain,  the  inferior  mesenteric  ganglion  and  the  hypogastric  plexus ;  2,  abdominal  brain; 
3  great  splanchnic  ;  4,  small  splanchnic  ;  5,  superior  mesenteric  artery;  6,  renal  ganglion  ;  7, 
renal  artery  with  its  ganglionic  plexus  surrounding  it;  8,  superior  mesenteric  ganglion;  9, 
ramus  communicans;  10,  lumbar  lateral  chain;  11,  inferior  mesenteric  artery  surrounded  by 
its  plexus;  12,  13,  sacro-iliac  point;  14,  innominate  vein;  15,  innominate  artery;  16,  ramus 
communicans  to  inferior  mesenteric  ganglion;  17,  ramus  communicans;  18,  lateral  chain ; 
19,  right  renal  artery;  20,  splanchnic  minor;  21,  renal  ganglion;  22,  splanchnic  ganglion; 
23,  splanchnic  major;  24  ad-renal;  25,  ganglion  phrenicum. 


36  THE  ABDOMINAL  AND  PELVIC  BRAIN 

The  chief  manifestation  of  the  vasomotor  nerve  is  that  it  is  endowed 
with  a  peculiar  rhythmical  phenomenon.  The  ganglia  of  the  nervus 
vasomotorius  alone  possess  rhythm.  (Some  advocate  that  muscle 
possesses  inherent  power  of  rhythm,  however,  so  far  it  is  found  in  muscle 
supplied  by  the  sympathetic  nerve,  e.  g.,  muscles  of  the  various  visceral 
tracts.) 

The  vasomotor  nerve  is  particularly  connected  to  the  cerebrum  through 
the  vagi  (proximal  end)  and  to  the  spinal  cord  by  the  sacral  nerves  (distal 
end). 

The  vasomotor  nerves  may  pass  directly  from  the  bilateral  chain  of 
ganglia  to  the  viscera  without  passing  through  intervening  ganglia  or 
plexuses,  viz.:  (a)  pharyngeal  plexuses  located  at  the  bifurcation  of  the 
carotids;  (b)  the  cardiac  plexus — located  at  the  origin  of  the  aorta  from 
the  heart;  (c)  the  cceliac  plexus  (abdominal  brain)  located  at  the  origin  of 
the  cceliac  axis  from  the  aorta;  (d)  the  pelvic  plexus  (pelvic  brain)  located 
originally  at  the  bifurcation  of  the  aorta.  These  four  great  ganglionated 
nerve  plexuses  are  located  intermediary  between  the  bilateral  vasomotor 
ganglionic  chain  and  the  automatic  visceral  ganglion  located  in  relation  with 
the  organs.  The  vasomotor  ganglia  are  originating  centers  for  nerve  fibers, 
hence  there  is  no  relation  between  the  number  of  nerve  fibers  which  enter 
(afferent)  and  the  number  of  nerves  which  depart  (efferent)  from  a  ganglion. 
The  ganglia  of  the  vasomotor  nerve  (composed  of  ganglion  cells)  may  be 
viewed  as  nervous  centers,  i.  e.,  receive,  reorganize  and  emit  nerve  forces — 
to  which  all  the  physiologic  and  pathologic  phenomena  of  the  viscera  may  be 
referred.  The  three  prominent  systems  or  series  of  ganglia  constituting  the 
vasomotor  nerve,  for  convenience  of  description  and  practical  purposes,  may 
be  termed:  (a)  primary  ganglia  (the  vasomotor  bilateral  chain).  They  appear 
assomatic  or  segmental  in  location  on  the  lateral  borders  of  the  vertebra;  (b) 
secondary  ganglia  (the  four  great  prevertebral  plexuses).  They  appear  to  be 
located  in  relation  to  major  blood-vessels,  ventral  to  the  vertebra;  (c) 
tertiary  ganglia  (automatic  visceral  ganglia).  They  appear  to  be  located  in 
relation  to  viscera ;  in  or  on  visceral  wall.  The  vasomotor  visceral  plexuses 
differ  as  much  in  arrangement  from  the  vasomotor  bilateral  chain  as  the 
latter  does  from  the  spinal  cord. 

The  prevertebral  plexuses  form  a  kind  of  fusion  between  the  cerebro- 
spinal and  vasomotor  nervous  systems;  also  they  solidly  and  compactly 
anastomose,  unite  the  bilateral  ganglionic  vasomotor  chain  and  the  automatic 
visceral  ganglia  as  well  as  fuse  the  lateral  halves  of  the  nervus  vasomotorius. 
The  signification  of  the  vagi  nerves  may  be  observed  when  it  was  noted  that 
they  assist  in  the  formation  of  three  of  the  four  great  prevertebral  vasomotor 
plexuses  (see  a,  b,  c,  above). 

There  is  a  peculiar  balanced  relation  between  the  vagi  and  vasomotor 
nerves.  In  animals  especially,  but  also  in  man,  there  is  a  tendency  to  fusion 
of  the  vagi  and  vasomotor  nerves.  They  act  vicariously  for  each  other. 
The  greater  the  dimensions  of  the  vasomotor  nerves  the  less  the  dimensions 
of  the  vagi  and  vice  versa.     The  vagi  are  practically  visceral  nerves  supplying, 


ABD0MIX.1L  VASOMOTOR  NERVE 


37 


viz. :  larynx,  lung,  heart,  gastrium,  liver,  pancrea.  The  vasomotor  plexuses 
differ  essentially  from  nerve  plexuses  formed  by  the  cerebrospinal  nerves.  In 
cerebrospinal  nerve  plexuses  the  afferent  and  efferent  nerves  are  identical, 
however  the  afferent  and  efferent  cords  may  be  differently  combined 
previous  to  entrance  and  subsequent  to  the  formation  of  the  plexus. 

The  efferent  branches  departing  from  the  plexus  are  precisely  the  same 
as  the  afferent  branches  that  entered  it.     On.  the  contrary,  in  the  vasomotor 

.9 

.1 

15 


LUMBAR  AND  SACRAL  PORTIONS  OF  THE  SYMPATHETIC 

Fig.  5.  1,  incised  edge  of  diaphragm;  2,  lower  end  of  oesophagus;  3,  left  half  of  stom- 
ach; 4,  small  intestine;  5,  sigmoid  flexure  of  the  colon;  6,  rectum;  7,  bladder;  8,  prostate; 
9,  lower  end  of  left  vagus  ;  10,  lower  end  of  right  vagus;  11,  solar  plexus;  12,  lower  end  of 
great  splanchnic  nerve;  13,  lower  end  of  lesser  splanchnic  nerve ;  14,  14,  two  last  thoracic 
ganglia ;  15,  15,  the  four  lumbar  vertebra? ;  16,  16,  17,  17,  branches  from  the  lumbar  ganglia ; 
18,  superior  mesenteric  plexus;  19  21,  22,  23,  aortic  lumbar  plexus;  20,  inferior  mesenteric 
plexus  ;  24,  24,  sacral  portion  of  the  sympathetic  ;  25,  25,  26,  26,  27,  27,  hypogastric  plexus ;  28, 
29,  30,  tenth,  eleventh  and  twelfth  dorsal  nerves ;  31,  32,  33,  34.  35,  36,  37,  38,  39,  lumbar  and 
sacral  nerves.     (Sappey,  1810.) 


38  THE  ABDOMIXAL  AXD  PELVIC  BRA IX 

nerve  plexuses  there  is  no  relation  in  dimension,  number  and  structure  of 
the  afferent  and  efferent  nerves  with  each  other  and  the  vasomotor  nerve 
plexus  itself.  The  mode  of  distribution  of  the  cerebrospinal  and  vasomotor 
nerves  differ. 

The  cerebrospinal  nerves  practically  follow  blood  vessels;  however,  they 
divide  by  acute  angles  and  do  not  form  plexiform  sheaths  around  blood 
vessels. 

The  vasomotor  nerves  are  generally  distributed  in  the  plexiform  network 
ensheathing  vessels  and  entering  with  them  into  the  parenchyma  of  viscera. 
From  the  reason  that  the  vasomotor  nerves  are  distributed  in  a  plexiform 
gangliated  network  intimately  ensheathing  vessels  (especially  arteries)  con- 
tinuously to  their  destination,  i.  e.,  to  the  viscera,  it  has  long  originated 
the  idea  that  the  nervus  vasomotorius  belongs  exclusively  to  the  vascular 
system  (blood,  lymph  vessels).  This  view  was  especially  promulgated 
by  Claude  Bernard,  a  French  physiologist  in  1K51  (1813-1873).  The  vaso- 
motor nerves  accompany  the  arteries  not  the  veins,  the  trunk  of  the  vena 
porta  forming  the  exception  to  the  rule.  In  this  chapter  of  applied  anatomy 
and  physiology  of  the  nervus  vasomotorius  abdominalis  I  shall  mention 
essential  features  only  for  practical  reasons.  I  shall  consider  in  order 
regardless  of  any  exact  system  the  following  subjects:  Chapter  IV,  truncus 
sympathicus;  Chapter  V,  nervus  plexus  aorticus  abdominalis;  Chapter  VI, 
nervus  plexus  interiliacus;  Chapter  VII,  nervi  tractus  intestinalis;  Chapter 
VIII,  nervi  tractus  urinarius;  Chapter  IX,  nervi  tractus  genitalis;  Chapter  X, 
nervi  tractus  vascularius;  Chapter  XI,  nervi  tractus  lymphaticus;  Chapter 
XII,  the  abdominal  brain  (cerebrum  abdominale) ;  Chapter  XIII,  pelvic  brain 
(cerebrum  pelvicum). 


CHAPTER    IV. 

THE  TRUNK   OF  THE    SYMPATHETIC    NERVE— (NERVUS 
TRUNCUS  SYMPATHICUS). 

"One  glorious  hour  of   conquering   strife   is   worth  an  age  of  quiet  peace." 

— Shakespeare. 

We  do  well  what  we  do  automatically. 

The  trunk  of  the  vaso-motor  (sympathetic)  nerve  has  experienced  a 
variety  of  names: 

Synonyms:  The  lateral  cords  of  the  sympathetic;  the  principal  cords  of 
the  sympathetic;  the  lateral  ganglionic  chain  of  the  sympathetic;  the 
nodular  cords  of  the  sympathetic. 

German:     Grenzstrang,  Hauptstrang,  Knotenstrang. 

The  nerve  strands  connecting  the  ganglia  of  the  sympathetic  trunk  are 
termed  commissural  cords.  The  trunk  of  the  sympathetic  nerve  presents 
the  form  of  an  elongated  elipse  enclosing  the  vertebral  column,  united  at  the 
proximal  and  distal  ends  by  unpaired  ganglia.  The  trunk  consists  of  a 
vertical,  symmetrical,  bilateral  ganglionated  cord  with  indefinite  union  at  the 
proximal  end  (ganglion  of  Ribes)  and  distal  ends  (Ganglion  Coccygeum). 
The  number  of  ganglia  and  roots  correspond  in  general  to  the  number  of 
spinal  nerves.  Exceptions  occur  in  which  the  ganglia  coalesce,  as  in  the 
reduction  of  the  seven  cervical  to  the  usual  number  of  three.  The  total 
number  of  trunk  ganglia  (3,  cervical),  (11,  dorsal),  (4,  lumbar)  and  (4,  sacral) 
vary  from  20  to  25.  The  form  of  the  trunk  ganglia  varies  and  may  be 
elongated,  olive,  spindle,  triangle,  pyramidal,  irregular  shaped.  The 
ganglia  in  general  are  located  ventral  to  the  transverse  processes  and  on  the 
lateral  surfaces  of  the  vertebrae.  However,  the  relation  of  the  ganglia  in 
each  segment  to  the  vertebra  varies.  The  trunk  ganglia  vary  in  dimension 
from  Y\  of  an  inch  long  (inferior  cervical  ganglion)  to  less  than  the  size  of 
a  grain  of  wheat.  The  terminations,  both  proximally  and  distally,  of  the 
elongated  elliptical  ganglionated  trunk  are  obscurely  united  by  ganglia  or 
commissura,  cords. 

A  ganglion  is  composed  of  a  larger  or  smaller  number  of  multipolar  nerve 
cells  enclosed  in  a  capsule  of  connective  tissue. 

RAMI  COMMUNICANTES. 

The  bilateral  symmetrical  vertical  ganglionated  trunk  of  the  sympa- 
thetic is  connected  to  the  spinal  cord  by  means  of  the  rami  communicantes, 
which  are  two  bands  of  nerves  extending  from  the  spinal  nerves  to  the 
ganglia  of  the  trunk  of  the  sympathetic.  These  central  communicating 
branches  are  known  as  gray  (sympathetic)  and  white  (visceral)  rami  com- 
municantes.     The    ganglionated   trunk    of    the    sympathetic    nerve    emits 

89 


40  THE  ABDOMINAL  AND  PELVIC  BRAIN 

important  visceral  branches  from  its  different  segments  (cervical,  dorsal, 
lumbar  and  sacral)  to  the  viscera  of  the  thoracic,  abdominal  and  pelvic 
cavities.  The  following  table  will  present  a  bird's-eye  view  of  the  segments 
of  the  trunk  of  the  sympathetic  nerve  with  their  important  branches. 

SUPERIOR  MEDIAN  GANGLION  (RIBES)    (GANGLION   SUPERIOR   MEDIUS). 

fl.  Superior  cervical  ganglion  (ganglion  cerv- 

I.  Trunk   of   the    cervical    sympathetic   j  2  Middle 'c^rvica^'ganglion  (ganglion  cervi- 

(Truncus  Sympathies  Cervicales).    \  cale  medium). 

1  wo  to  three.                                             3^  inferjor  cervical  ganglion  (ganglion  cervi- 

(.  cale  inferior). 

II.  Trunk  of  the  dorsal  sympathetic.  \  EmitsVplalTchnic  nerves. 

(Truncus  Sympathies  Dorsahs).  ]  (Coeliac  Plexus). 

III.  Trunk  of  the  lumbar  sympathetic.  Four  to  five. 

(Truncus  Sympathies  Lumbalis).  |  Emits  lumbar  branches  to  plexus  aorticus. 

IV.  Trunk  of  the  pelvic  sympathetic.  fp        ,     ~ 

(Truncus  Sympathies  Pelvinus).  ]  _     .        .  , 

v  J     ^  Emits  visceral  nerves. 

INFERIOR    MEDIAL   GANGLION    (GANGLION    COCCYGEUm). 

I.     Branches  of  the  Cervical  Trunk  of  the  Sympathetic. 


The  cervical  sympathetic  trunk  is  a  projection  proximalward  (toward 
the  cranium)  along  the  great  cervical  vessels. 

The  branches  of  the  three  cervical  ganglia  and  commissural  cord  are 
distributed  to  structures  of  the  head,  neck  and  thorax  and  consist  of: 

(a)  Motor  fibres  to  involuntary  muscles  (pupil  dilators). 

(b)  Vaso-motor  fibres  to  head,  neck  and  proximal  limbs. 

(c)  Pilo-motor  fibres  along  cervical  spinal  nerves. 

(d)  Cardiomotor  fibres. 

(e)  Secretory  fibres. 

The  trunk  cervical  ganglia  are  located  on  the  prevertebral  muscles 
dorsal  to  the  carotid  artery.  It  extends  from  the  first  rib  to  the  base  of  the 
skull. 

The  cervical  sympathetic  trunk  is  characterized  by  the  absence  of  the 
white  rami  communicantes.  The  cervical  ganglia,  usually  coalesced,  from 
seven  to  three  in  number,  are  important  on  account  of  the  emitting  of  the 
pharyngeal  plexus  and  cardiac  nerves. 

A.   Superior  Cervical  Ganglion  (Ganglion  Cervicale  Superius). 

Synonyms:     Supreme  cervical  ganglion  (ganglion  cervicale  supremum); 

Fig.  6.  The  trunk  of  the  vasomotor  nerve  here  presented  was  dissected  under  alcohol 
with  care  as  regards  connexions  and  relations.  The  ellipse  formed  by  the  two  lateral 
trunks  is  evident.  The  ellipse  extends  from  the  cranium  to  the  coccyx.  The  two  nerve 
trunks  are  especially  united  at  the  cranium  (cervical  part)  at  the  coeliac  axis  (abdominal 
part)  and  the  distal  end  (pelvic  part).  Between  the  two  lateral  trunks  of  the  nervus  vasomo- 
torius  lies  the  plexus  aorticus,  thoracicus,  cerebrum  abdominale,  plexus  aorticus  abdominalis, 
intenliac  nerve  disc,  plexus  interiliacus,  cerebrum  pelvicum. 


Fig  6.    TRUNK  OF  THE  VASOMOTOR  NERVE  (Truncus  Vasomotorius). 


42  THE  ABDOMINAL  AND  PELVIC  BRAIN 

the  great  cervical  ganglion  (ganglion  cervicale  magnum);  the  fusiform 
cervical  ganglion  (ganglion  cervicale  fusiforme);  the  olive-shaped  cervical 
ganglion  (ganglion  cervicale  olive). 

The  superior  cervical  ganglion,  %  of  an  inch  in  length  is  the  largest  of 
the  sympathetic  trunk  ganglia.  It  is  located  at  the  base  of  the  skull  between 
the  internal  jugular  vein  and  internal  carotid  artery.  It  is  irregular  in  form, 
however,  chiefly  spindle-shaped.  The  commissural  cord  connects  it  to  the 
middle  cervical  ganglion. 

The  main  branches  of  the  superior  cervical  ganglion  are: 

Cpntral  rnmmnnicatin?  branches  \  L  Gray  rami  communicantes  (no  white). 

Central  communicating  branches  j  2    Communicantes  with  cranial  nerves. 

(  3.  Emits  branches  to  pharynx. 
Peripheral  branches  of  the  distribution,  -j  4.  Emits  superior  cervical  cardiac  nerves. 

(  5.  Branches  to  vessels  (controlling  lumen). 

B.  Middle  Cervical  Ganglion  (Ganglion  Cervicale  Medium). 
Synonyms:     The  thyroid  ganglia  (Ganglion  Thyroideum). 
The  middle  cervical  ganglion  sends  branches: 

1.  (Central  Communicating  Branches)  gray  rami  communicantes  (no 
white). 

2.  The  subclavian  loop  (Ansa  Vieusseni.  French  anatomist,  1641-1716) 
enclosing  the  subclavian  artery  and  joining  the  middle  and  inferior  cervical 
ganglia. 

3.  Peripheral  branches  of  distribution,  the  middle  cervical  cardiac  nerve. 

4.  Branches  to  the  thyroid  body. 

C.  Inferior  Cervical  Ganglion  (Ganglion  Cervicale  Inferius). 
Synonyms:     The  first  thoracic  ganglion  (Ganglion  Thoracicum  primum) ; 

the  vertebral  ganglion  (Ganglion  Vertebrale) ;  the  stellate  ganglion 
(Ganglion  Stellatum). 

The  inferior  cervical  ganglion  is  irregular  in  dimension,  form,  location 
and  branches.     The  inferior  cervical  nerve  emits: 

1.  (Central  Communicating  Branches)  gray  rami  communicantes 
(no  white). 

2.  Subclavian  loop. 

3.  Communications  with  larynx. 

4.  (Peripheral  branches  of  distribution).     The  inferior  cervical  cardiac 

nerve. 

-     -d         u      4.  i  i  (a)  Vertebral  plexus, 

o.   Branches  to  vessels  \  >,  \  c  ,    i     •  Jf    , 

(  (b;  Subclavian  plexus. 

The  bilateral  trunks  of  the  cervical  sympathetic  are  not  directly  united 

by  transverse  nerve  strands. 

II.     Branches  of  the  thoracic  or  dorsal  trunk  of  the  Sympathetic. 


The  dorsal  or  thoracic  ganglia  composing  the  dorsal  or  thoracic  trunk  of 
the  sympathetic  generally  consists  of  eleven  ganglia  of  varied  form  and 
dimension  connected  by  commissural  cords  of  marked  dimension.  The 
important  feature  of  the  thoracic  sympathetic  trunk  is  that  the  distal  five  or 
six  ganglia  give  origin  to  the  three  splanchnic  or  visceral  nerves  which  richly 


Branches     of     the    thoracic    sympathetic 
trunk. 


THE  TRUNK  OF  THE  SYMPATHETIC  NERVE  43 

supply  the  abdominal  viscera.  The  branches  forming  the  ganglionated 
thoracic  cord  may  be  divided  into  two  kinds  (a)  central  branches  connecting 
with  other  nerves;  (b)  peripheral  branches  distributed  in  a  plexiform 
manner  to  the  thoracic  and  abdominal  viscera.  The  significant  feature  of 
the  thoracic  trunk  of  the  sympathetic  is  the  presence  of  the  white  rami 
communicantes  (visceral  nerves).  The  central  communicating  branches  are 
(both)  the  white  and  gray  rami  communicantes.  The  peripheral  branches  of 
distribution  of  the  thoracic  trunk  arise  both  from  the  ganglia  and  the 
commissural  cord.  The  important  distributing  branches  in  the  practice  of 
medicine  for  the  abdominal  viscera  are  the  three  splanchnic  nerves;  the  distal 
ends  of  the  splanchnic  nerves  practically  form  the  abdominal  brain — the 
visceral  ruler  of  the  peritoneal  organs.  The  splanchnic  nerves  are  the 
abdominal  visceral  nerves.  The  following  table  presents  a  bird's  eye  view 
of  the  branches  of  the  thoracic  sympathetic  trunk: 

fl.  (Central   communicating   branches)    white 
rami  communicantes. 

2.  Gray  rami  communicantes. 

3.  (Peripheral  branches  of  distribution). 
Pulmonary  (from  II,  III  and   IV  ganglia) 

to  form  the  pulmonary  plexus. 

4.  Aortic  (from  proximal  5  ganglia)  to  supply 
aorta. 

5.  The  three  splanchnic  nerves  (from  the 
distal  7  thoracic  ganglia  and  commissural 
cords)  to  supply  the  abdominal  viscera. 

A.  The  Great  Splanchnic  Nerve     (Nervus  Splanchnicus  Major). 

arises  from  the  thoracic  trunk  between  the  fifth  and  ninth  ganglia.  By  the 
coalescence  of  several  irregular  strands  a  nerve  of  marked  dimension  is 
formed  which  passes  distalward  in  the  dorsal  mediastinum  and  perforating 
the  crus  of  the  diaphragm  terminates  as  the  principal  mass  of  the  abdominal 
brain  (semilunar  ganglion).  The  great  splanchnic  ganglion  (ganglion 
splanchnicum  maxium)  is  found  on  the  trunk  of  the  great  splanchnic  nerve 
within  the  thoracic  cavity. 

B.  The  Small  Splanchnic  Nerve     (Nervus  Splanchnicus  Minor). 

The  small  splanchnic  nerve  arises  from  the  trunk  of  the  thoracic  sympa- 
thetic in  the  region  of  the  ninth  and  tenth  ganglia.  It  courses  adjacent  to 
the  bodies  of  the  distal  thoracic  vertebrae,  perforates  the  crus  of  the  dia- 
phragm adjacent  to  or  with  the  great  splanchnic  and  terminates  irregularly 
in  the  abdominal  brain,  (and  occasionally  in  the  so-called  aortic-renal 
ganglion). 

C.  The  Least  Splanchnic   Nerve     (Nervus   Splanchnicus   Minimus 

(inferior  or  tertius). 

The  least  splanchnic  nerve  arises  from  the  last  thoracic  ganglion  in  the 
sympathetic  trunk  (or  from  the  small  splanchnic).  It  perforates  the 
diaphragm  and  terminates  in  the  plexus  renalis.  The  bilateral  thoracic 
trunks  of  the  sympathetic  are  not  directly  united  by  the  transverse  nerve 
strands  similar  to  the  lumbar  and  sacral  trunks. 


44  THE  ABDOMINAL  AND  PELVIC  BRAIN 

III.  Branches  of  the  Lumbar  Sympathetic  Trunk. 

The  lumbar  trunk  of  the  sympathetic  consists  usually  of  four  ganglia 
joined  by  commissural  cords.  It  is  continuous  proximally  with  the  thoracic 
and  distally  with  the  sacral  trunk  of  the  sympathetic.  The  lumbar  trunk  is 
located  on  the  bodies  of  the  lumbar  vertebrae  internal  to  the  origin  of  the 
psoas  muscle  and  ventral  to  the  lumbar  vessels.  The  lumbar  ganglia  are  not 
always  bilaterally  symmetrical  in  dimension,  location,  distance  from  each 
other  and  form.  The  ganglia  are  larger  than  those  of  the  dorsal  or  sacral 
trunk.  The  commissural  cords  of  the  lumbar  sympathetic  trunk  are  longer, 
stronger  and  more  irregular  in  number  than  the  dorsal  or  sacral.  The 
branches  from  the  lumbar  gangliated  trunk  consist  of  two  sets,  viz. : 

A.  Central  Communicating  Branches. 

1.  The  first  two  or  three  lumbar  spinal  nerves  possess  visceral  branches 
which  form  white  rami  commnnicantes  joining  the  proximal  lumbar  ganglia 
or  commissural  cord. 

These  white  rami  communicantes  comprise  vaso-motor  fibres  for  the 
tractus  genitalis  and  motor  fibres  for  the  uterus  and  bladder. 

2.  Gray  Rami  Communicantes  which  pass  to  the  ventral  primary 
divisions  of  the  lumbar  nerves.  The  rami  communicantes  (white  and  gray) 
are  irregular  in  length,  dimension  and  location. 

B.  Peripheral  Branches  of  Distribution  from  the  lumbar  ganglia  and 
commissural  cord  arises  and  pass  to  the  plexus  aorticus  and  aorta.  The 
lumbar  sympathetic  trunk  sends  branches  to  the  plexus  ureteris.  The 
branches  are  irregular  in  length,  dimension,  number  and  location.  The 
bilateral  sympathetic  trunk  is  directly  united  by  several  transverse  nerve 
strands,  chiefly  extending  from  ganglion  on  one  side  to  that  on  the  other. 

IV.  Branches  of  the  Sacral  Sympathetic  Trunk. 

The  sacral  trunk  of  the  sympathetic  is  a  continuation  of  the  lumbar 
trunk.  It  terminates  in  a  plexiform  coalescence  over  the  coccyx  with  the 
trunk  of  the  opposite  side.  The  distal  termination  of  the  sacral  sympa- 
thetic trunks  are  known  as  the  ganglion  impar  or  coccygeal  ganglion.  There 
are  usually  four  ganglia  which  united  by  a  commissural  cord  decrease  in 
dimension  from  sacral  promontory  to  coccyx.  The  ganglia  are  generally  not 
bilaterally  symmetrical  in  location,  dimension  or  equidistant  from  each 
other.  The  usual  location  is  on  the  ventral  surfcae  of  the  sacrum  on  the 
internal  border  of  the  sacral  foramina.  The  ganglia  scralia  vary  in  number, 
dimension,  location  and  form.  The  bilateral  sacral  sympathetic  trunks  are 
united  directly  by  numerous  transverse  nerve  cords  which  are  arranged  in  a 
plexiform  manner  (which  I  have  termed  plexus  intertrunci  sacralis).  The 
middle  sacral  trunk  of  the  sympathetics,  like  that  of  the  cervical  and  distal 
lumbar  receives  no  white  rami  communicantes  from  the  spinal  nerves. 

The  visceral  branches  (Pelvic  Splanchnic)  of  the  II,  III  and  IV  sacral 
nerves  join  the  pelvic  plexus  (pelvic  brain)  without  being  directly  connected 
with  the  sacral  sympathetic  trunk.  These  nerves,  however,  are  to  be  con- 
sidered homologous  with  the  white  rami  communicantes  of  the  thoracic  and 
lumbar  (abdominal  splanchnics). 


THE  TRUNK  OF  THE  SYMPATHETIC  NERVE  r, 

The  II,  III  and  IV  sacral  nerves  transmit  to  the  tractus  genitalis  (uterus) 
tractus  intestinalis  (rectum)  and  tractus  urinarius  (bladder)  motor  and  inhib- 
itory nerves,  and  also  vaso-dilator  fibres  for  the  tractus  genitalis. 

The  branches  of  the  sacral  sympathetic  trunk  are  of  two  kinds,  viz. : 

A.  Central  Communicating  Branches. 

I.  Gray  rami  communicantes  arise  from  the  ganglia  and  join  the  ventral 
primary  division  of  the  sacral  and  coccygeal  nerves.  There  are  no  white  rami 
communicantes. 

B.  Peripheral  Branches  of  Distribution  are: 

1.  Visceral  branches  of  limited  dimension  which  arise  mainly  from  the 
proximal  ganglia  of  the  trunk  and  commissural  cord  and  pass  medianward  to 
join  the  interiliac  plexus  and  pelvic  brain  as  well  as  the  three  kinds  of  pelvic 
viscera  and  adjacent  vessels. 

2.  Parietal  branches  limited  in  dimension  which  ramify  on  the  ventral 
surface  of  the  sacrum,  especially  in  relation  with  the  sacral  artery,  forming 
what  I  have  termed  the  plexus  intertrunci  sacralis. 

The  four  segments  of  the  trunk  of  the  sympathetic  nerve,  cervical, 
dorsal,  lumbar  and  sacral,  differ  according  to  location  and  environment. 

The  white  rami  communicantes  (visceral  nerves  abdominal  splanchnics) 
stream  from  the  dorsal  and  proximal  lumbar  ganglia. 

The  visceral  nerves  of  the  pelvic  sympathetic  trunk  (pelvic  splanchnics) 
do  not  pass  through  the  sacral  ganglia  but  through  the  II,  III  and  IV 
sacral  nerves. 

The  distributing  branches  of  the  pelvic  sympathetic  trunk  are  the  least 
important  of  any  segmental  trunk.  The  bilateral  cervical  and  dorsal  sympa- 
thetic trunks  are  practically  not  directly  united  by  transverse  nerve  cords, 
the  bilateral  lumbar  and  pelvic  trunks  are  united  by  numerous  transverse 
nerve  cords  (and  plexuses). 

The  bilateral  cervical  sympathetic  trunks  are  united  by  two  localized 
prevertebral  plexuses,  the  pharyngeal  and  cardiac. 

The  bilateral  dorsal  sympathetic  trunks  are  united  by  a  single  prever- 
tebral colossal  pelvus — abdominal  brain. 

Ganglionic  coalescence  occurs  chiefly  in  the  cervical  trunk.  The 
ganglia  are  the  most  irregular  in  the  pelvic  trunk,  the  largest  in  the  cervical 
and  lumbar  trunks. 

The  commissural  cords  are  multiple  supernumerary  in  the  lumbra  and 
sacral  trunks  only. 

The  cervical  sympathetic  trunk  and  pelvic  brain  are  the  only  segments 
so  far  subject  to  surgical  intervention  (extirpation). 


CHAPTER  V. 

PLEXUS   AORTICUS  ABDOMINALIS.— (A)  ANATOMY, 
(B)  PHYSIOLOGY. 

One's  rainbow  of  desires  changes  color  with  the  passing  years. 

"Instead  of  condemning  me  to  death  the  city  (Athens)  should  grant  me  a  pen- 
sion."    The  defense  presented  by  Socrates  in  his  trial. 

(a)   ANATOMY. 

The  plexus  of  the  abdominal  aorta  extends  from  the  coeliac  artery  to 
the  aortic  bifurcation.  It  extends  from  the  abdominal  brain  to  the  hypo- 
gastric ganglion  or  disc.  At  the  proximal  end  of  the  aortic  plexus  is  located 
the  abdominal  brain,  at  the  distal  end  is  located  the  hypogastric  ganglion  or 
disc.  It  consists  of  a  wide  meshed  network  of  anastomosing  nerve  bundles 
and  ganglia.  The  main  nerve  cords,  two  in  number,  course  parallel  to  the 
lateral  borders  of  the  abdominal  aorta,  constituting  the  aortic  plexus,  anas- 
tomosing with  each  other  by  means  of  nerve  strands  coursing  obliquely  or 
transversely  ventral  or  dorsal  to  the  aorta,  and  also  with  the  lateral  chain  of 
lumbar  ganglia  by  means  of  short  nerve  cords.  The  plexus  aorticus 
practically  ensheaths  the  aorta,  especially  ventrally,  with  a  wide  meshed 
network  of  nerves  and  ganglia. 

(a)    The  Ganglia  of  the  Plexus  Aorticus. 

The  ganglia  of  the  aortic  plexus  are  numerous  and  important,  being 
located  practically  at  the  origin  of  visceral  vessels  from  the  aorta.  They 
consist  of  multiple  bordered,  irregularly  flattened  bodies  located  mainly  on  the 
ventral  and  lateral  borders  of  the  aorta.  Originally  the  aortic  plexus  consisted 
of  a  bilateral  gangliated  cord  located  along  the  lateral  aortic  border,  each 
ganglion  representing  the  origin  and  mission  of  a  visceral  vessel.  By 
evolutionary  processes  and  change  of  attitude  the  ganglia  become  removed, 
changed  from  this  original  site  which  was  at  the  origin  of  the  arterial  vessels. 
In  general  the  ganglia  of  the  plexus  of  the  abdominal  aorta  are  located  at  the 
exit  of  the  visceral  vessels  from  the  aorta  abdominalis,  viz. :  (a)  ganglion 
diaphragamaticum  (paired),  located  on  the  proximal  border  of  the  abdominal 

Fig.  7.  This  illustration  is  from  a  dissection  made  under  alcohol.  It  is  a  drawing 
from  a  subject  possessing  a  typical  large  abdominal  brain  with  the  ureter,  bladder  and 
urethra  dilated  into  a  single  channel  without  sphincters  intact.  1  and  2,  abdominal  brain ; 
3  and  4,  renal  plexuses  ;  5,  plexus  adrenalis  ;  6  and  7,  the  two  vagi ;  8  and  9,  the  three  splan- 
chnics  on  each  side;  10,  two  spermatic  ganglia;  11  inferior  mesenteric  ganglia;  12  and  13 
lumbar  lateral  chain  of  ganglia;  14  and  15,  dilated  ureters  wrapped  by  nerve  plexuses;  16 
arterio-ureteral  crossing ;  17,  hypograstic  plexuses ;  18,  and  19,  lateral  chain  of  sacred  gang- 
lia; A  and  B,  Patulous  ureteral  orifices.  The  Plexus  aorticus  extends  from  the  abdominal 
brain  (1  and  2)  to  the  aortic  bifurcation,  whence  the  Plexus  interiliacus  (hypogastricus) 
begins  and  extends  to  the  Pelvic  brain.  I  consider  the  Plexus  Aorticus  in  this  subject  as  a 
typical  one. 

46 


Fig.  7.     PLEXUS  AORTICUS  ABDOMINALIS 


48  THE  ABDOMINAL  AND  PELVIC  BRAIN 

brain  in  the  form  of  a  conical  projection  simulating  the  olfactory  bulbs  of 
the  cranial  brain;  (b)  ganglion  coeliacum  (unpaired),  located  at  the  origin  of 
the  coeliac,  superior  and  inferior  mesenteric  and  renal  arteries;  (c)  Ganglion 
renalis,  located  at  the  origin  of  the  arteria  renalia;  (d)  ganglion  ovaricum 
(paired),  located  at  the  origin  of  the  arteria  ovarica;  (e)  ganglion  mesenteri- 
cus  inferior  (unpaired),  located  at  the  origin  of  the  arteria  mesenterica  infe- 
rior; (f)  ganglion  hypogastricum  (unpaired),  a  coalesced  disc  located  at  the 
origin  of  the  arteria  iliacacommunicus  at  the  aortic  bifurcation.  The 
hypogastric  ganglion,  or  disc,  arises  at  the  bifurcation  of  the  abdominal 
aorta.  Its  existence  is  according  to  the  rule  (modified  by  environments  and 
erect  attitude)  that  a  sympathetic  ganglion  occurs  at  the  exit  of  the 
abdominal  visceral  arteries  from  the  aorta  abdominalis. 

The  position  of  the  ganglia  appears  to  have  experienced  changes  with 
evolutionary  development  as  they  become  transported  by  detachment  from 
the  base  of  the  visceral  artery  toward  the  corresponding  viscus  or  along 
bones  and  muscles.  Some  visceral  arteries,  like  the  renal,  possess  a  wealth 
of  separate  ganglia.  The  ganglia  are  located  in  general:  (a)  at  the  origin 
of  the  visceral  artery  from  the  aorta ;  (b)  along  the  lateral  borders ;  (c)  on 
the  ventral  surface  of  the  vessel.  The  ganglia  mainly  surround  the  root  of 
the  visceral  vessel  like  a  collar  or  fenestrated  sheath  and  encase  it  towards 
its  viscus  with  a  plexiform  network  of  nerves. 

The  dimension  of  the  ganglia  in  the  aortic  plexus  practically  correspond 
with  the  volume  of  the  corresponding  visceral  artery.  The  longest  ganglion 
is  that  of  the  arteria  coeliaca.  The  smallest  constant  ganglion  is  perhaps 
that  at  the  base  of  the  arteria  diaphragmatic. 

The  form  of  the  ganglia  are  oval,  triangular  or  multiple  bordered 
flattened  bodies.  The  surface  of  the  ganglia  are  uneven,  with  irregular, 
fenestrated  spaces  and  occasionally  perforated  by  blood  vessels. 

(b)    The  Nerve   Trunks  and  Cords  of  the  Plexus  Aorticus. 

The  ganglia  of  the  aortic  plexus  are  united  or  anastomosed  into  a  wide 
meshed  plexus  by  two  general  methods:  (1)  By  two  trunk  cords  extending 
along  the  lateral  borders  of  the  aorta  from  the  ganglion  coeliacum  to  the 
ganglion  hypogastricum  or  hypogastric  discs;  (2)  by  cords  of  smaller  and 
larger  caliber  coursing  irregularly  from  ganglion  to  ganglion,  from  cord  to 
cord  and  from  one  lateral  trunk  to  the  other.  The  plexus  aorticus  is  solidly 
and  compactly  united  to  the  bilateral  chain  of  lumbar  ganglia  by  short, 
strong  strands  and  to  all  visceral  nerve  plexuses  of  the  abdomen. 

The  plexus  aorticus  practically  ensheaths  the  abdominal  aorta  (especially 
lateral,  and  ventrally)  with  a  plexiform  network  of  nerve  cords  and  ganglia. 
From  the  plexus  aorticus  abdominalis  arise:  (a)  the  plexus  diaphragmaticus 
(paired),  which  accompanies  and  ensheaths  the  arteria  diaphragmatica  (the 
right  possesses  a  ganglion) ;  (b)  plexus  coeliacus  (unpaired),  which  accompanies 
and  ensheaths  the  arteria  gastrica  (supplying  the  stomach),  hepatica  (supply- 
ing the  liver)  and  lienalis  (supplying  the  spleen) ;  (c)  the  plexus  mesentericus 
superior  (unpaired),  which  accompanies  and  ensheaths  the  arteria  mesenterica 


PLEXUS  AORTICUS  ABDOMINALIS  49 

superior  with  a  network  of  nerve  cords  and  ganglia  to  supply  the  enteron, 
right  colon  and  right  half  of  transverse  colon;  (d)  plexus  renalis  (paired), 
which  accompanies  and  ensheaths  the  arteria  renalis  with  a  network  of  nerve 
cords  and  wealth  of  ganglia  to  supply  the  kidney  and  proximal  ureter;  (e) 
plexus  ovaricus  (paired),  which  accompanies  and  ensheaths  the  arteria 
ovarica  with  a  network  of  nerve  cords  and  ganglia  to  supply  the  ovary, 
oviduct  and  ligament  a  lata;  (f)  plexus  mesentericus  inferior  (unpaired), 
which  accompanies  and  ensheaths  the  arteria  mesenterica  inferior  with  a 
mesh-work  of  nerves  and  ganglia  to  supply  the  right  half  of  the  transverse 
colon,  right  colon,  sigmoid  and  rectum;  (g)  plexus  hypogastrics  (unpaired 
coalesced)  which  originally  accompanied  and  ensheathed  the  arteria  hypogas- 
trica  with  a  network  of  nerve  cords  and  ganglia  to  supply  tractus  genitalis 
(especially  the  uterus  and  vagina)  and  distal  segment  of  the  tractus  urinarius 
(especially  the  bladder  and  distal  segment  of  the  ureter).  The  plexus 
aorticus  abdominalis  includes  the  abdominal  aorta  from  the  coeliac  axis  to 
its  bifurcation  on  the  sacral  promontory,  hence  its  profound  connection  to 
every  abdominal  visceral  tract  through  the  arteries.  The  vital  signification 
of  the  plexus  aorticus  abdominalis  is  at  once  evident  when  it  is  observed 
that  from  it  issues  practically  nine  great  visceral  arteries  (the  coeliac,  two 
mesenteric,  two  renals,  two  ovarian  and  two  iliacs)  accompanied  by  great 
nerve  plexuses  and  having  at  least  one  marked  sympathetic  ganglion  at  their 
origin.  Each  of  the  eight  nerve  plexuses  of  the  plexus  aorticus  are  solidly 
and  compactly  anastomosed  with  every  other  plexus  and  connected  with  all 
other  abdominal  plexuses,  making  a  compact  network  of  abdominal  sympa- 
thetic nerves  perfectly  planned  to  report  functions  to  the  ruling  potentate, 
the  abdominal  brain. 

(b)     physiology. 

The  physiology  of  the  plexus  aorticus  abdominalis  comprises  the 
function  of  the  viscera  to  which  it  supplies  nerves  viz. :  tractus  intestinalis, 
urinarius,  genitalis,  vascularis  and  lymphaticus.  The  three  great  common 
functions  of  the  abdominal  viscera  are:  (a)  Peristalsis,  absorption,  sensation 
and  secretion.  To  the  common  functions  must  be  added  for  the  tractus  geni- 
talis, (d)  ovulation;  (e)  menstruation ;  (f)  gestation.  We  unconsciously  employ 
the  physiology  of  the  aortic  plexus  in  the  practice  of  obstetrics  for  uterine 
haemorrhage.  When,  after  parturition,  there  is  undue  bleeding  the  physician 
attempts  to  check  it  by  compressing  the  aorta.  He  is  in  error  for  what  the 
practitioner  really  performs  is  to  irritate  the  aortic  plexus  and  this  results 
in  exciting  uterine  contraction,  the  uterine  muscular  and  elastic  bundles  act 
like  living  ligatures  which  limits  the  lumen  of  the  vessels.  In  irritating  the 
aortic  plexus  no  trauma  or  roughness  need  be  employed.  Simple,  light 
stroking  of  the  abdomen  or  gentle  kneading  will  quickly  stimulate  the  aortic 
plexus  which  sends  branches  to  supply  the  uterus  through  the  pelvic  brain, 
inducing  it  to  contract  and  check  haemorrhage.  The  peristalsis  of  labor  may 
be  hastened  by  administering  hot  drinks  to  the  patient.  The  heat  in  the 
stomach  stimulates  the  aortic  plexus  through  the  gastric  plexus  and  conse- 

4 


50 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


quently  the  nerves  which  supply  the  uterus  inducing  more  vigorous  and 
frequent  uterine  rhythm.  Friction  on  the  nipple  or  massage  of  the  breasts 
will  induce  more  frequent  and  vigorous  uterine  rhythm  during  labor.  The 
stimulation  from  the  mammae  travels  to  the  abdominal  brain  (and  conse- 
quently to  the  aortic  plexus  and  uterus)  over  the  nerve  plexus  accompanying 
the  mammary,  intercostal,  inferior  epigastric  arteries.  In  abdominal 
massage  we  apply  practical  physiology  to  the  various  abdominal  visceral 
tracts.  For  example  in  constipation  one  or  all  the  great  visceral  functions 
(peristalsis,  absorption,  sensation  and  secretion)  are  defective.  By  stimulating 
the  aortic  plexus  through  massage  intestinal  peristalsis,  secretion  and  absorp- 
tion are  enhanced  as  the  irritation  passes  over  the  gastric  plexus  to  the  stom- 
ach over  the  superior  mesenteric  plexus  to  the  enteron  and  over  the  inferior 


PLEXUS  AORTICUS  ABDOMINALIS 

Fig.  8.  This  illustration  represents  a  typical  aortic  plexus,  which  I  dissected  under 
alcohol  from  a  specimen  taken  from  a  subject  of  about  fifty  years  of  age.  1  and  2  abdominal 
brain  lying  at  the  foot  of  the  great  abdominal  visceral  arteries.  P.  O.  S.  ganglia  located  at 
the  other  visceral  arteries.     HP,  represents  the  fenestrated  interiliac  nerve  disc. 


PLEXUS  AORTIC  IS  ABDOMINALIS  51 

mesenteric  plexus  to  the  colon.     Constipation  may  be  cured  by  massage  of 
the  abdomen.       Massaging  the  abdominal  brain  induces  more  active   renal 
peristalsis,  absorption  and  secretion.       The  physiology  of  the  sympathetic 
presents  a  vast  field  for  future  therapeutics,   especially  in  the  direction  of 
visceral    massage.       The    massage    of   the    abdominal    sympathetic    (plexus 
aorticus)  will  assume  three  directions  of  physiologic  utility,  viz. :      (a)  The 
great  ganglia  of  the  plexus  aorticus  will  be  stimulated,  that  is,  the  ganglion 
at  the  root  of  each  visceral  artery  will  be  stimulated,  which  will  excite  the 
pulsating  vessel  (and  the  heart),  supplying  more  blood  to  its  corresponding 
viscus  and  consequently  individual  and  collective  visceral  peristalsis,  absorp- 
tion and  secretion  is  enhanced — this  is  administering  a  vascular  tonic.     It 
also  aids  visceral  drainage  which  consists  in  elimination  of  waste  laden  blood 
and  lymph  products.     In  short,   massage  of  the  plexus  aorticus  abdominalis 
enhances  visceral  function  (rhythm)  and  visceral  drainage  (elimination) ;  (b) 
massage  of  the  plexus  aorticus  enables  the  operator  to    manipulate    each, 
individual,  viscus  which  not  only  excites  the  capsule  or  muscularis  of  the 
organ  to  enhance  peristalsis,  but  the  parenchyma  of  each  viscus  receives  a 
direct  stimulus  for  increased  absorption  and  secretion.     This  is  again  admin- 
istering a  natural  tonic  for  the  massage  of  a  viscus  enhances  its  function  and 
drainage.     Visceral  stimulation  and  visceral  drainage  must  be  complements 
and  compensatories  of  each  other;  (c)  in  performing  massage  of  the  plexus 
aorticus    abdominalis,   the  voluntary  abdominal  muscles  are  invigorated  in 
function    and   usefulness.       The   active   contraction    and   relaxation    of  the 
abdominal  muscles  on  the  viscera  is  a  necessity  for  their  normal  function 
(rhythm,  absorption,  secretion)  and  support,  e.  g.,  splanchnoptotics  possess 
relaxed  abdominal  walls  and  consequent  distalward  movements  of    viscera 
and   elongated   mesenteries — resulting  in  disturbed,   compromised,    visceral 
peristalsis,  absorption  and  secretion  as  constipation,  indigestion  and  neuras- 
thenia.    Every   organ  has  its  rhythm.     In  the  rhythm  or  peristalsis  of  an 
organ  undoubtedly  lies  the  physiologic  secret  of  correlated  secretion  and 
absorption.      Hence  one  of  the  essential  duties  of  a  physician  is  to  aid  in 
maintaining  a  normal  visceral  rhythm.     In  conditions  of  acute  inflammation 
or  irritation   of  viscera,  the   abnormally  active   rhythm    is  best  treated  by 
anatomic  (quietude  of  voluntary  muscles)  and  physiologic  rest  (prohibition 
or  control  of  fluid  and  foods).       In  conditions  of  defective  rhythm  of  organs 
as  in  constipation,  splanchmoptosia,  the  best  means   to   stimulate   normal 
rhythm  is  systematic  abdominal  massage  and  vigorous  visceral  drainage.     A 
rational  method  to  stimulate  visceral  rhythm  is  to  administer  coarse  foods 
(cereals  and  vegetables)  that  leaves  a  large  fecal  residue  which  irritates  the 
intestines  into  vigorous  peristalsis  or  rhythm. 


CHAPTER  VI. 

THE  VASOMOTOR  INTERILIAC  PLEXUS  (PLEXUS  INTER- 
ILIACUS  VASOMOTORIUS— SYMPATHICUS). 

Immaterial,  irrelevant,  incompetent. — Attorney's  objection  to  evidence  in  law 
trials. 

Industry  wins  living,  honesty  wins  respect. 

Extending  from  the  abdominal  brain  (the  coeliac  axis)  to  the  pelvic 
brain  (cervico-uterine  junction)  there  exist  two  rich  and  mighty  nerve 
plexuses,  plexus  aorticus  and  plexus  interiliacus. 

For  convenience  of  description  and  significance  in  practice  I  will  divide 
this  plexus  into  two  grand  divisions,  viz. : 

(a)  The  plexus  aorticus  extending  from  the  coeliac  axis  to  the  aortic 
bifurcation;  (b)  the  plexus  hypogastricus  or  more  significantly  plexus 
interiliacus,  which  extends  from  the  bifurcation  of  the  aorta  (sacral  promon- 
tory) to  the  junction  of  uterus  and  vagina.  The  plexus  interiliacus  is 
important  because  it  is  the  great  highway  of  travel  for  afferent  (initiative 
or  spontaneous)  and  efferent  (reflex  peripheral)  genital  nerve  forces.  I 
shall  view  the  plexus  interiliacus  as  originally  belonging  and  accompanying 
the  common  iliac  vessels.  However,  by  erect  attitude,  distalward  movements 
of  the  tractus  genitalis  and  increasing  dimensions  (especially  lateralward)  to 
the  pelvis,  coalescence  of  the  proximal  extremities  of  the  two  branches  of 
the  plexus  interiliacus  arose.  That  is,  the  original  nerve  plexuses  accompany- 
ing the  common  iliac  arteries  gradually  moved  medianward  from  them. 
Hence  the  term  plexus  interiliacus  is  particularly  appropriate.  The  plexus 
interiliacus  has  experienced  a  variety  of  names  during  the  past  two  centuries. 
Synonyms:  Superior  hypogastric  plexus  (plexus  hypogastricus  superior, 
Tiedemann,  1822).  Medial  hypogastric  plexus  (plexus  hypogastricus 
medius).  Impar  (odd,  single,  impaired)  hypogastric  plexus  (plexus  hypo- 
gastric impar).  Interiliacal  plexus  (plexus  interiliacus,  Waldeyer,  living). 
The  great  uterine  plexus  (plexus  uterinus  magnus,  Tiedemann,  1822). 
Pelvic  plexus  (plexus  pelvicus,  Thomas  Snow  Beck,  1845,  1814,  1847).  The 
hypogastric  ganglion,  i.  e.,  layer  (lamina  gangliosa  hypogastrica,  Gabriel 
Gustave  Valentine,  German  anatomist,  1810-1883).  The  common  uterine 
plexus  (plexus  uterinus  communis,  Tiedemann,  1822).  Iliac  plexus  (plexus 
iliacus — anatomica  nomina,  Basel).  Distal  part  of  the  aortic  plexus  (plexus 
aorticus  distal,  Henle — Fred  Gustav  Jacob  Henle,  German  anatomist, 
1809-1885). 

The  plexus  interiliacus  I  shall  consider  under  three  distinct  headlines, 
viz.:  (a)  interiliacal  nerve  disc  (proximal  end);  (b)  trunk  of  the  plexus 
interiliacus  (central  segment) ;  (c)  pelvic  brain  (distal  end  or  ganglion 
cervicale). 

52 


THE  I'ASOMOTOR  INTERILIAC  PLEXUS 


53 


PLEXUS  INTERILIACUS 

Fig.  9  This  illustration  presents  the  sympathetic  nerves  following  the  arteries.  I 
dissected  this  specimen  (man  40)  with  care,  and  the  artist,  Mr.  Klopper,  sketched  exactly 
from  the  model.  1  and  2,  abdominal  brain.  Pn,  Pneumogastric  nerve;  sp.  Nervus 
Splanchnicus  major.  Ad,  adrenal ;  Dg,  ganglion  diaphragmaticum ;  Adn,  10  adrenal 
nerves  (right),  (left),  7.  G.  R.  arteria  renalis  (right  and  left  partially  duplicate).  N. 
Ganglia  renalia  (left).  Ur,  ureteral  nerves.  S.  G.  and  5  upper  ganglia  spermatica.  I,  gang- 
lion mesentericum  inferior;  X,  ganglionic  coalescence  of  nerves  at  the  vasa  spermatica  and 
ureteral  crossing.  5  ganglionic  coalescence  of  the  nerves  at  the  crossing  of  the  ureter  and 
vasa  iliaca  communis.  IB,  Plexus  interiliacus  (hypogastricus)  surrounding  the  rectum. 
ID  is  the  fenestrated  nerve  disc  of  the  sacral  promontory.  V,  Vena  cava  emitting  the 
vena  ovarica  on  which  is  ensheathed  the  plexus  ovaricus. 


54  THE  ABDOUIXAL  AXD  PELVIC  BRAIN 

(a)  INTERILIAC    NERVE  DISC. 

The  proximal  end  of  the  plexus  interiliacus,  which  I  shall  term  the 
interiliacal  nerve  disc  of  the  sacral  promontory,  is  practically  a  plexus  of 
nerve  cords  compressed  or  flattened  dorso-ventrally.  The  interiliacal  disc  is 
the  result  of  coalescence  of  the  distal  end  of  the  plexus  aorticus,  located  at 
the  aortic  bifurcation,  practically  on  the  sacral  promontory  and  the  distal- 
ward  movements  of  the  tractus  genitalis  producing  traction  and  extension 
on  the  nerve  disc  of  the  sacral  promontory.  The  interiliac  nerve  disc  is 
practically  a  plexiform  nerve  mass  located  at  the  proximal  end  of  the  plexus 
interiliacus.  The  arrangement  of  the  interiliacal  disc  consists  in  the  coal- 
escence on  the  same  promontory  of  the  afferent  nerve — plexus  aorticus  and 
branches  from  the  distal  bilateral  lumbar  ganglia — and  the  emission  of  efferent 
nerves:  (a)  two  bilateral  large  plexuses  to  the  pelvic  brain;  (b)  branches  to 
the  tractus  intestinalis  (rectum  haemorrhoidal) ;  (c)  branches  to  the  tractus 
genitalis  (uterus,  vagina,  oviduct);  (d)  branches  to  the  tractus  urinarius 
(ureter,  bladder). 

POSITION. 

I.  Holotopy  (relation  to  general  body).  The  interiliac  nerve  disc  is 
located  on  the  median  line  in  the  space  between  the  major  bifurcation  and 
the  distal  end  of  the  abdominal  end  cavity  immediately  proximal  to  the  lesser 
pelvis.  It  is  a  coalesced  unpaired  organ  situated  extraperitoneally  on  the 
sacral  promontory,  dorsal  to  the  peritoneum.  It  is  strongly  ensconced  in 
connective  tissue  at  the  most  accessible  portion  of  the  abdomen  for  palpa- 
tion. 

II.  Skeletopy  (relation  to  osseous  system).  The  interiliac  nerve  disc 
lies  on  the  ventral  surface  of  the  distal  lumbar  and  proximal  sacral  vertebrae. 
It  lies  practically  on  the  brain  of  the  inner  osseous  pelvis. 

III.  Syntopy  (relation  to  adjacent  viscera).  The  interiliac  nerve  disc, 
coalesced  (unpaired),  is  located  centrally  in  the  space  between  the  major 
aortic  bifurcations  which  practically  includes  the  ventral  surface  of  the  two 
distal  lumbar  and  two  proximal  sacral  vertebras.  It  is  securely  ensconced  in 
strong  dorsal  subperitoneal  connective  tissue.  It  is  situated  between  the 
peritoneum  and  pelvic  fascia.  The  interiliac  nerve  disc  is  limited  to  the 
space  between  the  coalescence  of  the  plexus  aorticus  (aortic  bifurcation)  and 
the  emission  or  divergence  of  the  plexus  interiliacus  (second  sacral  verte- 
bras). The  interiliac  nerve  disc  lies  dorsal  to  certain  changeable  mobile 
loops  of  the  enteron  and  mesenteron  and  possess  variable  relations  to  the 
sigmoid  and  mesosigmoid.  In  peritonotomy,  in  spare  subjects,  the  inter- 
iliac nerve  disc  may  be  observed  shimmering  whitish  through  the  dorsal 
peritoneum. 

IV.  Idiotopy  (relation  of  the  component  segments).  The  interiliac 
nerve  disc  consists  of  a  nerve  plexus  compressed,  flattened,  dorso-ventrally, 
and  interspersed  with  fenestra  of  varying  number  and  dimension.  The 
fenestra  increase  in  number  and  dimension  from  proximal  to  distal  borders. 
Dimensions.     The  interiliacal  disc  is  some  two  inches  in  length  and  three- 


THE  VASOMOTOR  INTERILIAC  PLEXUS 


55 


fourths  of  an  inch  in  width.  Form.  The  form  is  that  of  truncated  cone. 
The  lateral  borders  are  bounded  by  nerve  cords.  The  proximal  border  fuses 
with  the  plexus  aorticus.  The  distal  border  coalesces  with  the  emerging 
efferent  lateral  interiliacal  plexuses. 

GENERAL  REMARKS  IN   REGARD  TO  THE   INTERILIAC  NERVE  DISC. 

It  consists  of  a  flattened,  band-like  nerve  plexus  in  a  sheath  of  firm , 
dense,  connective  tissue,  located  in  the  interval  between  the  two  common 
iliac  arteries.  It  is  formed  by  a  continuation  of  the  plexus  aorticus  plus 
prolongations  from  the  ganglia  lumbales.     It  is  a  flat  plexiform  nerve  mass 


PIC.    6.  —  PELVIC    I1RAIN. 

PLEXUS  INTERILIACUS  OF  ADULT 

Fig.  10.  This  specimen  I  dissected  with  care  under  alcohol.  The  plexus  interiliacus 
extends  from  the  discus  interiliacus  (D)  to  the  pelvic  brain  (A).  Observe:  (1)  Two 
nerve  strands  are  emitted  from  the  interiliac  plexus  to  the  uterus  previous  to  passing 
through  the  pelvic  brain  (A).  (2)  Note  the  contribution  of  the  lateral  sacral  chain  of  gang- 
lia and  II  and  III  sacral  nerves  to  the  plexus  interiliacus.  (3)  Bear  in  mind  the  intimate 
relation  of  the  plexus  interiliacus  to  the  rectum  proximalward  and  distalward. 

at  the  junction  of  the  distal  lumbar  and  proximal  sacral  vertebrae.  I  have 
termed  it  the  interiliac  nerve  disc,  as  it  contains  no  constant  distinct  ganglia. 
Some  authors  claim  it  contains  no  ganglia,  while  others  claim  it  contains 
some  ganglia,  the  latter  being  the  more  probable.  The  interiliac  disc  is 
significant  as  it  emits  (efferent  nerves)  from  its  distal  border,  the  two  nerve 


5G  THE  ABDOMINAL  AND  PELVIC  BRAIN 

plexuses  which  rule  the  pelvic  viscera.  The  interiliac  nerve  disc  is  an 
example  of  the  principle  elsewhere  noted  that  at  every  emission  of  a  major 
(visceral)  artery  from  the  abdominal  aorta  there  exists  a  ganglion  (or  nerve 
disc).  Practically  there  should  be  two  ganglia  at  the  aortic  bifurcation. 
However,  coalescence  occurred  and  one  ganglion  or  disc  resulted — the 
interiliac  nerve  disc  (or  ganglion).  Efferent  nerve  branches  from  the 
interiliac  disc  not  only  accompany  the  two  common  iliac,  ovarian,  superior 
haemmorhoidal  and  sacral  arteries  but  emit  the  two  great  interiliac  plexuses 
(for  the  pelvic  viscera)  as  well  as  branches  to  the  ureters,  left  colon  and 
sigmoid.  The  interiliac  nerve  disc  is  important  in,  practice  because  it  is 
practically  accessible  to  manipulation,  massage.  By  gentle  irritation  or 
massage  of  the  interiliac  disc  in  post  partum  haemorrhage  the  plexus 
interiliacus  will  be  stimulated,  which,  supplying  the  uterus,  will  induce  the 
elastic  and  muscular  bundles  of  the  myometrium  to  act  like  living  ligatures, 
limiting  the  uterine  vessels,  and  checking  haemorrhage.  It  is  not  the 
supposed  constriction  of  the  aorta  that  checks  the  haemorrhage. 

(b)  TRUNCUS    PLEXUS    INTERILIACUS    SYMPATHICUS. 

The  trunk  or  central  segment  of  the  interiliac  plexus  (paired)  extends 
from  the  interiliac  nerve  disc  to  the  pelvic  brain.  The  plexus  interiliacus 
consists  not  merely  of  nerve  strands,  for  it  is  composed  of  nerve  plexuses 
the  commissures  and  cords  of  which  are  band  or  ribbon-like  in  character 
surrounding  apertures  or  fenestra  of  various  dimensions  which  increase  in 
area  toward  the  distal  end.  The  plexus  interiliacus  increases  in  breadth 
from  proximal  to  distal  end,  i.  e.,  from  interiliac  nerve  disc  to  pelvic  brain. 
The  proximal  end  is  relatively  small  and  composed  of  a  few  nerve  cords,  the 
distal  end  is  broad  and  divides  into  numerous  branches.  The  course  of  the 
interiliac  plexus  is  proximally  along  the  internal  side  of  the  pelvic  vessels 
while  distally  it  courses  along  the  dorsal  and  rectal  wall  with  which  it  is 
intimately  connected  by  connective  tissue  and,  when  it  again  resumes  inti- 
mate association  with  the  pelvic  vessels  the  length  of  the  trunk  of  the 
plexus  interiliacus  averages  some  3/4  inches.  Numerous  nerve  branches 
from  the  V  lumbar  ganglion  and  from  the  I,  II,  III  and  IV  sacral  ganglia 
join  the  external  border  of  the  plexus  interiliacus.  From  the  internal 
border  of  the  plexus  interiliacus  numerous  branches  pass  to  the  rectum, 
ureter,  uterus,  vagina,  bladder.  From  the  plexus  pass  numerous  nerves  to 
the  pelvic  vessels.  The  trunk  of  the  plexus  interiliacus  is  profoundly 
associated  with  the  rectal  wall,  sharing  in  its  movements  or  contraction  of 
and  dilatation.  The  intimate  and  profound  connections  of  the  trunk  of 
the  plexus  interiliacus  with  the  rectal  wall  explains  the  favorable  therapeutic 
value  of  the  rectal  enema  due  to  stimulation  of  the  plexus.  The  rectum  is 
practically  surrounded,  ensheathed  by  two  great  bilateral  interiliac  plexuses, 
i.  e.,  the  rectum  lies  in  the  boot-jack  angle  produced  by  the  divergence  of 
the  plexuses.  The  plexus  interiliacus  possesses  a  remarkable  anatomic 
feature,  which  is  that  it  sends  some  two  strong  nerves  directly  to  the  uterus 
without  first  passing  through  the  pelvic  brain  (demonstrated  with  very 
extraordinary  facility  in  infant  cadavers). 


THE  VASOMOTOR  IXTER1LIAC  PLEXUS 


57 


PLEXUS  INTERILIACUS  (with  interiliac  nerve  disc,  115). 

Fig.  11.  I  dissected  this  specimen  in  1894  from  a  spare  subject  having  enormously 
large  vasomotor  nerves'  The  aorta  divided  into  the  iliacs  at  the  junction  of  the  III  and  IV 
lumbar  vertebrae.  112,  genital  ganglion  ;  173,  third  lumbar  ganglion  (R) ;  114,  genito-rectal 
ganglion;  103,  lumbar  lateral  chain  of  ganglia;  173,  third  lumbar  nerve  (R)  ;  90,  lumbar 
nerve ;  91,  lumbar  nerve ;  179,  fourth  lumbar  ganglion  (R)  ;  104,  lateral  chain  of  ganglia ; 
181  com.  iliac  artery  arising  in  this  case  at  third  lumbar  vertebra;  188,  inferior  renal  gang- 
lia; 174,  fourth  lumbar  nerve  (R)  ;  189,  fifth  lumbar  ganglion  (R)  ;  93,  lumbar  nerves  ;  114, 
genital  ganglion  ;  115,  hypogastric  plexus  ;  134,  first  sacral  ganglion  (L)  ;  179,  fourth  lumbar 
ganglion  (R)  ;  116  hypogastric  plexus  ;  125,  lumbo-sacral  cord  ;  135,  first  sacral  ganglion  (K) ; 
136,  genital  ganglion;  118,  hypogastric  plexus;  126,  first  sacral  nerve  (L)  ;  1/0,  lumbar 
sacral  cord;  130,  first  sacral  nerve  (R)  ;  158,  right  sacral  plexus;  137  second  sacral  gang- 
lion;  117,  hypogastric  plexus;  156,  rectum;  127,  second  sacral  nerve  (L).  trom  authors 
life-size  chart  on  the  sympathetic  nerve. 


58  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(c)    DISTAL  END  OF  THE  PLEXUS   INTERILIACUS  OR  PELVIC  BRAIN. 

The  broad  distal  end  of  the  plexus  interiliacus,  a  plexiform  fenestrated 
nerve  mass,  unites  with  the  branches  of  the  II,  III  and  IV  sacral  nerves  to 
form  the  pelvic  brain  (ganglion  cervicale).  The  resulting  union  of  the  distal 
end  of  the  plexus  interiliacus  and  sacral  nerves — a  plexiform  ganglionated 
mass,  the  pelvic  brain — rules  the  physiology  of  the  pelvic  viscera,  especially 
the  vascularity  of  the  genitals.  The  pelvic  brain  is  elsewhere  described  in 
detail. 

GENERAL   REMARKS   ON   THE   PLEXUS    INTERILIACUS. 

The  plexus  interiliacus,  like  the  plexus  aorticus,  is  one  of  the  great  and 
important  nerve  plexuses  of  the  abdomen.  It  practically  supplies  the 
tractus  genitalis;  distal  end  of  tractus  intestinalis  (rectal,  sigmoid) ;  and 
distal  end  of  tractus  urinarius  (ureter,  bladder).  The  plexus  interiliacus  is 
double,  bilateral,  presenting  practically  no  anastomosis.  It  is  accessible  to 
manipulation  through  the  abdominal  wall  as  well  as  per  rectum  and  per 
vaginam.  Dilatation  of  the  rectum  produces  its  favorable  therapeutic 
effects  through  the  plexus  interiliacus  by  flushing  the  capillaries  and  stimu- 
lating visceral  function,  especially  respiration.  The  plexus  interiliacus  is 
the  dominating  plexus  of  the  pelvis.  It  is  the  great  assembling  nerve  center 
of  the  pelvic  organs  and  is  solidly  and  compactly  bound  and  anastomosed  to 
all  other  pelvic  sympathetic  nerves  as  well  as  the  I,  II,  III  and  IV  sacral 
spinal  nerves.  The  following  table  presents  an  idea  of  the  vast  extent 
and  richness  of  distribution  of  the  branches  of  the  plexus  interiliacus.  It 
should  be  remembered  that  the  vast  majority  of  the  branches  of  the  plexus 
interiliacus  first  pass  through  the  pelvic  brain  before  supplying  the  pelvic 
viscera  (especially  those  to  the  tractus  genitalis). 

{  (Hemorrhoidal) 

.       ^  T  ,     ..     r  J      a,  colon  (left) 

b,  sigmoid 

c,  rectum 
ovary 
oviduct 

ligamentum  latum 
uterus 
vagina 

^pelvic  subserosium 

!  ureter 
bladder 
urethra 
.      ™  Tr         ,     .      \  arterial  plexuses  accompanying 

4.  Tractus  Vascularis    {  all  pelv£  arteries 

5.  Tractus  lymphaticus  (all  pelvic  lymphatic  glands  are  richly  supplied), 
A  peculiar  character  of  the  plexus  interiliacus  is  that  it  is  considerably 
disassociated  from  arterial  vessels — unlike  the  plexus  aorticus.  The  pelvic 
visceral  plexus  or  branches  of  the  plexus  interiliacus  possess  similar  features. 
On  the  contrary,  the  visceral  plexuses  or  branches  of  the  abdominal  brain 
notably  accompanying  the  visceral  arteries. 


2.     Tractus  Genitalis 


THE  VASOMOTOR  INTERILIAC  PLEXUS 


59 


AGE  RELATION   OF   THE   PLEXUS   INTERILIACUS. 

The  plexus  interiliacus  experiences  an  age  relation  according  to  the 
sexual  phases  as  presented  by  the  utero-ovarian  artery  in:  (a)  pueritas, 
(childhood),  a  quiescent,  undeveloped  state  with  limited  blood,  ganglion  cells 
and  neurilemma ;  (b)  pubcrtas,  a  developmental  state  (of  congestion)  of 
multiplication  of  ganglion  cells  and  increased  neurilemma;  (c)  menstrual 
phase,    a     functional   state   of  engorgement    (of   the   vaso   uterina),    which 


fiO-    3- — PELVIC   BRAIN   OF    ADULT. 

PLEXUS  INTERILIACUS  OF  ADULT 

Fig.  12.  This  specimen  I  dissected  under  alcohol.  D,  interiliac  nerve  disc.  Interiliac 
plexus  extending  from  the  interiliac  nerve  disc  (D)  to  the  pelvic  brain  (A).  Observe  :  (1) 
That  two  large  nerve  strands  are  emitted  from  the  interiliac  plexus  to  the  uterus  without 
first  passing  through  the  pelvic  brain.  (2)  The  plexus  interiliacus  is  intimately  associated 
with  the  rectum.  (3)  The  lateral  sacral  chain  of  ganglia  and  sacral  nerves  contributes 
branches  to  the  interiliac  plexus. 

The  II,  III,  IV,  and  V  sacral  nerves  contribute  to  form  the  pelvic  brain,  while  in  some 
specimens  the  I  sacral  nerve  contributes  a  branch  or  branches. 

further  increases  the  neurilemma  if  not  the  ganglion  cells;  (c)  gestation,  a 
state  of  complete  development  of  the  tractus  genitalis  (continuous  maximum 
engorgement  of  the  utero-ovarian  artery)  with  the  multiplication  of  ganglion 


CO  THE  ABDOMINAL  AND  PELVIC  BRAIN 

cells  and  periganglionic  tissue  with  neurilemma;  (d)  puerperium.  The 
elastic  and  muscular  bundle  of  the  myometrium  having  contracted  like  living 
ligatures,  the  enormous  volume  of  blood  passing  through  the  utero-ovarian 
artery  is  checked,  maximum  engorgement  suddenly  ceases,  the  ganglion  cells 
perhaps  remain  the  same  in  number,  however,  decreasing  in  dimension;  while 
the  periganglionic  tissue,  the  neurilemma  and  associated  connective  tissue 
decrease,  degenerate ;  (e)  climacterium.  This  phase  of  sexual  life  represents 
beginning  atrophy  from  lessening  of  blood  volume  in  the  utero-ovarian 
artery.  The  ganglion  cells  diminish  in  size  and  number  as  well  as  the 
periganglionic  tissue,  while  the  associated  connective  tissue  multiply;  (f), 
senescence.  This  is  the  atrophic  sexual  phase — death  of  parenchymatous  and 
increase  of  connective  tissue  framework  of  viscera.  The  muscularis  and 
elastic  fibres  of  the  myometrium  and  oviduct  decrease  while  the  connective 
tissue  increases.  The  wall  of  the  utero-ovarian  artery  increases  in  thickness 
while  the  lumen  decreases  in  dimension.  The  ganglion  cells  of  the  plexus 
interiliacus  decrease  in  number  and  dimension  while  the  ganglion  cell, 
nucleus  and  body  cell  outlines  become  less  distinct. 

The  periganglionic  connective  tissue  and  neurilemma  decrease  while 
the  associated  connective  multiplies.  In  senescence  the  plexus  interiliacus, 
which  was  originally  destined  for  the  tractus  genitalis,  gradually  fades  from 
its  maximum  dignity  of  structure  and  function.  Senescence  has  returned 
the  plexus  interiliacus  to  its  primitive  phase  of  pueritas  or  quiescent  existence. 

UTILITY   OF   THE    PLEXUS    INTERILIACUS    IN    PRACTICE. 

It  is  accessible  to  manipulation  from  proximal  to  distal  end  through  me 
abdomen,  per  rectum  or  per  vaginam.  Massaging  or  stimulating  the  plexus 
interiliacus  induces  the  muscular  and  elastic  bundles  of  the  organ  which  it 
supplies  to  contract  by  controlling  the  blood  volume.  The  most  typical 
example  for  the  employment  of  therapeutics  on  the  plexus  interiliacus  is 
during  post-partum  haemorrhage.  It  is  the  irritation,  massage  of  the  plexus 
interiliacus,  that  induces  muscular  and  elastic  bundles  of  the  myometrium  to 
contract  and  consequently  control  the  haemorrhages.  It  is  not  the  obstruc- 
tion produced  in  the  aorta  by  the  pressure,  the  technique  of  which  is 
almost  impossible,  for  the  two  ovarian  arteries  would  still  continue  to  force 
large  volumes  of  blood  to  the  uterus.  Light  abdominal  stroking,  digital 
manipulation  of  the  uterus  in  post-partum  haemorrhage  irritates,  massages 
the  plexus  interiliacus  and  its  branches,  which  induce  the  elastic  and  mus- 
cular bundles  of  the  uterus  to  contract  like  living  ligatures  on  the  blood 
vessels,  checking  haemorrhage.  The  so-called  uterine  inertia  of  long, 
tedious  labor  may  be  due  to  paresis  of  the  plexus  interiliacus  from  trauma  by 
the  child's  head.  Sudden  cessation  of  parturient  peristalsis— arrest  of  labor- 
is  doubtless  due  to  trauma  by  the  child's  head  on  the  plexus  interiliacus, 
a  sudden  paresis.  Vaginal  or  rectal  injections  (hot  or  medicated)  stimulate 
the  plexus  interiliacus,  hastening  labor.  Electricity  will  accomplish  similar 
effects.  The  flat,  band-like  form  of  the  plexus  interiliacus  protects  it  from 
trauma  during  parturition.     Massage  of  the  plexus  interiliacus  will  end  all 


THE  VASOMOTOR  INTERILIAC  PLEXUS  <;i 

alleviating  constipation  by  stimulating  active  peristalsis  and  secretion  of  the 
left  colon,  sigmoid  and  rectum.  The  plexus  interiliacus  may  be  stimulated 
by  means  of  hot  fluid  or  food  taken,  in  the  stomach.  The  irritation  passes 
from  the  stomach  over  the  plexus  gastricus  to  the  abdominal  brain,  whence 
it  is  reorganized  and  emitted  over  the  plexus  interiliacus,  inducing  more 
vigorous  uterine  contractions.  By  appropriate  systematic  massage  of  the 
plexus  interiliacus  stimulation  of  the  pelvic  viscera  may  be  effected,  resulting 
in  a  vigorous  circulation. 


CHAPTER  VII. 

THE  NERVES    OF  THE  TRACTUS    INTESTINALIS  (NERVI  TRAC- 
TUS  INTESTINALIS).— (A)  ANATOMY,   (B)  PHYSIOLOGY. 

"To  be  or  not  to  be,  that  is  the  question." — Shakespeare. 

"I  came,  I  saw,  I  conquered." — Ccesar's  report  to  the  Roman  senate. 

(a.)      ANATOMY. 

The  abdominal  sympathetic  emits  the  great  nerve  plexuses  to  the  tractus 
intestinalis  (accompanying  corresponding  named  arteries),  viz.:  (1)  plexus 
coeliacus  (unpaired)  consisting  of:  (a)  plexus  gastricus;  (b)  plexus  hepaticus; 
(c)  plexus  lienalis.  (2)  Plexus  mesentericus  superior  (unpaired);  (3)  plexus 
mesentericus  inferior  (unpaired);  (4)  plexus  haemorrhoidalis  medius  et 
superior  (paired).  The  above  five  nerve  plexuses  are  not  only  solidly  and 
compactly  anastomosed,  united  with  each  other  but  are  anastomosed,  con- 
nected with  all  other  abdominal  plexuses.  The  nerves  of  the  tractus 
intestinalis  are  motor  (rhythm,  peristalsis — Auerbach's  plexuses),  secretory 
(tubular  visceral  glands  Meissner's  plexus  and  glandular  appendages)  and 
sensory  (peripheral  reporters  to  the  abdominal  brain).  The  nerves  of  the 
tractus  intestinalis  are  preponderatingly  sympathetic,  however,  the  cranial 
(vagi)  share  in  supplying  the  proximal  segment. 

The  spinal  (second,  third  and  fourth  sacral)  share  in  supplying  the  distal 
segment. 

While  the  rami  communicantes  (spinal)  share  in  supplying  the  medial 
segment,  the  abdominal  brain  was  doubtless  a"  primitive  brain  for  the 
tractus  vascularis  and  secondarily  for  the  tractus  intestinalis. 

(1)  Plextis  Coeliacus  (Unpaired). 

The  coeliac  plexus  arising  from  the  abdominal  brain  is  about  one- 
half  inch  in  length,  encases  the  coeliac  artery  in  a  dense  plexi-form  net- 
work of  nerves,  cords,  commissures  and  ganglia.  It  is  the  largest  and  most 
luxuriant  sympathetic  plexus  surrounding  the  arteria  <:oeliaca  with  a 
rich,  closely  fenestrated  nerve  sheath,  solidly  united  by  connective  tissue. 
The  origin  of  the  coeliac  plexus  is  the  ganglion  coeliacum  located  in  the 
region  of  the  emission  of  the  great  visceral  arteries  including  three  sources 
of  nerves,  viz. :  (a)  vagus,  right  (cranial) ;  (b)  splanchnic,  the  most  important 
(spinal  cord,  rami  communicantes) ;  (c)  sympathetic.  The  plexus  coeliacus 
is  one  of  the  great  assembling  plexuses  of  the  abdomen.  It  divides  into 
three  branches  of  vast  importance  in  medical  practice,  viz. :  (a)  plexus 
gastricus;  (b)  plexus  hepaticus;  (c)  plexus  lienalis. 
(a)  Plexus  Gastricus  (Unpaired). 

62 


THE  NERVES  UP'   THE   TRACTUS  INTESTINALJS 


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ABDOMINAL  BRAIN  AND  CCELIAC  PLEXUS 

Fig.  13.  This  figure  presents  the  nerves  of  the  proximal  part  of  the  tractus  intestinal^ 
that  is,  the  nerve  plexuses  accompanying  the  branches  of  arteria  coeliaca.  1  and  2  abdominal 
brain  surrounding  the  cceliac  axis  drawn  from  dissected  specimen.  H.  Hepatic  plexus  on 
hepatic  artery.  S.  Splenic  plexus  on  splenic  artery.  Gt.  Gastric  plexus  on  gastric  artery 
Rn.  Renal  artery  (left).  R.  Right  renal  artery  in  the  dissection  was  rich  in  ganglia.  Dg. 
diaphragmatic  artery  with  its  ganglion.  G.  S.  Great  splanchnic  nerve.  Ad.  Adrenal.  K. 
Kidney.  Pn.  Pneumogastric  (Lt.  left).  Ep.  right  and  Eps.  left  epiploica  artery.  St.  Stom- 
ach Py,  Pyloric  artery.  C.  cholecyst.  Co.  chole-dochus,  N,  adrenal  nerves  (right,  10,  left  10). 
The  arterial  branches  and  loops  of  the  cceliac  tripod  (as  well  as  that  of  the  renals)  with  the: r 
corresponding  nerve  plexuses  demonstrate  how  solidly  and  compactly  the  viscera  of  the 
proximal  abdomen  are  anastomosed,  connected  into  single  delicately  poised  system  with  the 
abdominal  brain  as  a  center.  Hence  local  reflexes,  as  hepatic  or  renal  calculus,  disturb  the 
accurate  physiologic  balance  in  stomach,  kidney,  spleen,  liver  and  pancreas. 


64  THE  ABDOMINAL  AXD  PELVIC  BRAIX 

I.  Plexus  Gas  trims  Superior. — It  is  recognized  as  the  plexus  coro- 
narius  ventriculis  superior.  The  accompanying  table  illustrates  a  scheme  of 
gastric  nerve  supply. 

I.  Plexus  gastricus  superior  (sympathetic)  (plexus  coronarius  ventriculi 
superior). 

(a)  Plexus  ramus  dexter. 

(b)  Plexus  ramus  sinister. 

(2)  Plexus  gastricus  inferior  (sympathetic)  (plexus  coronarius  ventriculi 
inferior). 

(a)  Plexus  ramus  dexter  (arteria  hepatica). 

(b)  Plexus  ramus  sinister  from  (arteria  lienalis). 
3.     Vagi  plexuses  (cranial). 

Dorsal,  ventral  (cranial). 

The  gastric  or  superior  coronary  plexus  consists  of  a  fine  plexiform  net- 
work which  ensheathes  and  accompanies  the  curved  gastric  artery  along  the 
lesser  gastric  curvature.  It  lies  between  (however,  proximalward)  to  the  two 
gastric  plexuses  of  the  vagi  (cranial)  dorsal  and  ventral  anastomosing  with 
both,  hence  solidly  and  compactly  connecting,  uniting  the  gastric  plexuses 
(cranial)  with  the  gastric  plexuses  (sympathetic). 

II.  Plexus  Gastricus  Inferior.  (Unpaired).  This  is  recognized  as  plexus 
coronarius  ventriculi  inferior.  (The  inferior  gastric  or  coronary  plexus 
supplying  the  greater  curvature  is  mainly  from  the  hepatic  and  splenic 
plexuses  accompanying  the  arteria  gastro-epiploica  dextra  et  sinistra).  The 
stomach  is  supplied  by  the  cranial  (vagus),  right  phrenic  (spinal)  and  the 
sympathetic  nerves  from  the  plexus  coeliacus.  However,  since  the  sympa- 
thetic nerves  dominate  in  supply  to  the  stomach  it  possesses  a  rhythm  or 
peristalsis.  The  nerves  of  the  sympathetic  plexuses  at  first  course  beneath 
the  peritoneum  and  finally  penetrate  the  gastric  muscularis,  becoming 
Auerbach's  plexus,  destined  to  rule  the  gastric  rhythm.  The  ultimate 
+ermination  of  the  gastric  sympathetic  nerves  becomes  the  Meissner-Bilroth 
plexus  destined  to  rule  the  gastric  secretion  and  absorption.  The  gastric 
rhythm  is  modified  by  the  vagi  (cranial)  and  spinal  (ramus  communicantes 
and  phrenic).  The  location  of  the  gastric  nerves  is  important  by  reason  of 
the  diagnosis  of  gastric  disease  from  pain  and  reflexes. 

(b)  Plexus  Hcpaticus  (Unpaired). 

The  hepatic  plexus  (sympathetic)  arises  from  the  coeliac  plexus  and 
joining  with  the  hepatic  plexus  (cranial)  from  the  right  (and  left)  vagus 
accompanies  the  arteria  hepatica  as  a  coarse  plexiform  sheathed  network 
of  nerves  and  ganglion  (ganglia  hepatica). 

The  hepatic  plexus  consists  of  strong  flattened  nerves  arranged  in  the 
form  of  a  closely  fenestrated  meshwork,  surrounding  the  hepatic,  artery 
on  its  journey  through  the  liver.  A  peculiarity  of  the  hepatic  plexus  is  that 
it  emits  plexuses  to  ramify  on  the  vena  porta  and  its  branches  in  their  course 
through  the  liver.  The  hepatic  plexus  is  the  largest  and  coarsest  of  the  three 
branches  of  the  coeliac  plexus.     The  sympathetic  nerves  preponderate  in  the 


THE  NERVES   OE   THE   TRACTUS  INTESTINALIS  G5 

liver,   hence  it  possesses  a  rhythm  (through  its  elastic  capsule,    parenchy- 
matous cells,  vessels,  biliary  ducts). 

The  following  plexuses,  important  in  modern  practice,  are  branches  of 
the  hepatic  plexus: 

PLEXUS  HEPATICUS. 

1.  Plexus  arteriae  hepaticae. 

(a)  Plexus  ramus  communis. 

(b)  Plexus  ramus  dexter. 

(c)  Plexus  ramus  sinister. 

(d)  Plexus  arteriae  pylori. 

(e)  Plexus  arterias  gastricae  epiploicae  dextra. 

2.  Plexus  ductus  bilis. 

(f)  Plexus  ductus  choledochi. 

(g)  Plexus  ductus  cystici. 
(h)  Plexus  cholecysticus. 
(i)      Plexus  ductus  hepatici. 

3.  Plexus  vena?  portae. 

(j)      Plexus  ramus  communis, 
(k)     Plexus  ramus  dexter. 
(1)      Plexus  ramus  sinister. 

The  hepatic  nerve  plexus  accompanies  the  three  important  apparatus 
of  the  liver,  viz.:  (a)  artery;  (b)  biliary  channels;  (c)  portal  vein;  (d)  the 
liver  is  supplied  by  nerves  directly  and  indirectly  from  the  abdominal  brain. 

(a)  Plexus  arteries  Jiepaticce  consists  of  numerous  strong  gray  nerve 
fibres  arranged  in  a  plexiform  network  ensheathing  the  hepatic  artery.  At 
the  points  of  nerve  crossing  or  anastomosis  occur  flat  enlargements — ganglia 
hepatica.     The  plexiform  network  is  a  closely  fenestrated  sheath. 

The  branches  of  the  hepatic  plexus  accompanies  richly  the  branches 
of  the  hepatic  artery  through  the  five  liver  lobes;  they  accompany  the  pyloric 
artery  to  the  lesser  gastric  curvature;  they  ensheath  the  arteria  gastro 
epiploica  dextra  to  the  greater  gastric  curvature;  they  supply  the  duodenum 
and  caput  pancreatica  and  encase  the  two  arteries  which  supply  the  lateral 
borders  of  the  cholecyst.  In  short,  the  nerve  plexuses  accompany  the* 
hepatic  artery  and  all  its  branches. 

(b)  Plexus  ductus  bilis.  Nerves  of  the  biliary  channels  consist  of  a 
rich  plexiform  network  which  accompanies  and  ensheaths  each  segment  of 
the  biliary  passages,  viz.:  (1)  ductus  choledochus  communis;  (2)  ductus 
cysticus;  (3)  cholecyst ;  (4)  ductus  hepaticus.  Each  of  the  segments  of  the 
biliary  channels  possess  a  fine  meshed,  grayish  red,  nongangliated  nerve 
plexus.  The  localization  of  the  nerve  plexuses  of  the  biliary  passages,  the 
direction  of  their  reflexes  with  the  position  of  reorganized  focal  symptoms 
are  extremely  important  in  the  modern  practice  of  cholelithiasis  and  inflam- 
matory processes  in  the  segments  of  the  ductus  bilis.  In  dissecting  with  a 
magnifying  lens  it  is  evident  that  the  ductus  bilis  is  rich  in  nerve  plexuses. 
The  nerve   plexuses  of   the  biliary   channels  are  chiefly  derived  from  the 


66  THE  ABDOMIXAL  AND  PELVIC  BRAIN 

plexus  arteriae  hepaticae;  however,  large  numbers  of  nerves  pass  to  the  biliary 
channels  independent  from  the  abdominal  brain.  Especially  rich  and 
abundant  nerve  plexuses  are  found  accompanying  the  ductus  choledochus 
communis,  ductus  cysticus  and  cholecyst,  which  explains  the  severity  of 
the  pain  from  infection  of  any  of  its  segments  inducing  disordered,  wild, 
violent  peristalsis  of  the  bile  channels.  Recent  advances  in  surgery  of  the 
biliary  passages  have  directed  attention  to  the  nerve  supply  of  the  bile  chan- 
nels. Dissection  demonstrates  that  they  are  richly  supplied  with  numerous 
nerve  strands  and  ganglia  which  accounts  for  the  terrible  pain  in  cholecystitis 
calculosa.  The  different  segments  of  the  biliary  passages  are  so  abundantly 
supplied  with  nerves  that  they  have  assumed  the  name  plexuses.  The  sig- 
nificance of  the  nerves  of  the  biliary  channels  is  evident  in  pain  during 
the  passage  of  a  calculus  or  in  pain  from  localized  infection  of  any  segment 
of  the  bile  channels. 

(c)  Plexus  vena  porta  consists  of  a  strong  plexiform  network  of  nerves 
surrounding  and  accompanying  the  portal  vein  and  its  branches  through  the 
liver  parenchyma.  The  portal  vein  is  a  voluminous  tube  with  extensive 
ramifications  in  the  liver  and  hence  possesses  an  enormous  nerve  supply. 
The  sympathetic  nerve  is  destined  for  the  arteries;  however,  the  portal  vein 
is  a  marked  exception,  as  it  receives  an  abundant  sympathetic  nerve  supply. 
(I  have  traced  large  sympathetic  nerve  supplies  to  the  vena  cava  distal). 

The  liver  is  supplied  directly  from  the  abdominal  brain  (sympathetic): 
(a)  by  nerves  accompanying  the  arteria  hepatica ;  (b)  by  nerves  originating 
from  the  abdominal  brain  and  passing  directly  to  the  liver;  (c)  by  nerves- 
originating  in  the  abdominal  brain  and  accompanying  the  venae  portae ;  (d) 
(cranial)  vagi,  right  (and  left) ;   (e)  (spinal)  right  phrenic. 

(c)     Plexus  Licnalis   (Unpaired). 

Plexus  lienalis,  a  branch  of  the  coeliac  plexus,  a  fine  and  wide-meshed 
network  of  nerves  accompanying  the  spiral  splenic  artery  as  a  sheath  to  the 
spleen.     The  accompanying  table  presents  the  nerve  supply  of  the  spleen: 

PLEXUS  LIENALIS. 

(a)  Plexus  arteriae  lienalis. 

(b)  Plexus  ramus  gastricus. 

(c)  Plexus  ramus  pancreaticus. 

The  plexus  lienalis  is  less  in  dimension  than  the  plexus  hepaticus.  The 
splenci  plexus  is  joined  by  branches  from  the  right  vagus,  which  modifies 
the  splenic  rhythm.  It  furnishes  a  branch  plexus  to  the  arteria  gastrica 
epiploica  sinistra  which  courses  along  the  major  curvature  of  the  stomach  to 
meet  the  right  artery  of  corresponding  name.  It  emits  branch  plexuses  to 
the  pancreas.  The  splenic  plexus  emits  branches  from  the  omentum  majus. 
The  splenic  plexus  anastomoses  with  the  plexus  suprarenalis.  Practically 
the  splenic  plexus  supplies  the  left  half  of  the  stomach,  the  spleen,  and 
the  pancreas. 

The  main  nerves  of  the  plexus  lienalis,  much  diminished  from  omission 


THE   NERVES  OF   THE    TRACTUS  INTESTINALIS 


G7 


of  branches,  enters  the  hilum  of  the  spleen  with  the  sheath  of  the  splenic 
artery  to  be  distributed  to  the  splenic  parenchyma  to  the  Malpigian  bodies. 

(2.)     Plexus  Mesentericus  Superior     (Unpaired). 

The  superior  or  proximal  mesenteric  plexus  consists   of    large,   coarse, 
dense,   whitish  gray  nerve  fibres  which  arise  in  the  abdominal  brain  at  the 


THE  SOLID  AND  COMPACTLY  ANASTOMOSING  ARTERIES  OF  THE 
TRACTUS  INTESTINALIS 

Fig.  14.  This  illustration  demonstrates  that  the  arteries  of  the  tractus  intestinalis  are 
solidly  and  compactly  anastomosed  by  vascular  circles,  arcs  and  arcades.  To  recad  the 
plexus  vasomotorius  abdominalis  one  need  to  remember  the  arteriae  abdominalis  only.  The 
circles,  arcs  and  arcades  of  the  abdominal  arteries  are  richly  ensheathed  with  a  nodular 
plexus  of  nerves.  10  arteria  coeliaca  emitting  the  arterial  tripod  (tripus  Halleri),  hepatic, 
splenic  and  gastric,  presenting  circles,  arcs  and  arcades.  5  arteria  mesenterica  superior 
with  its  circles,  arcs  and  arcades.  7,  arteria  mesenterica  inferior  with  its  circles,  arcs  and 
arcades.  2-10,  gastro-hepatic  vascular  circle  (of  author)  anastomosed  to  the  circles,  arcs  and 
arcades  of  the  superior  mesenteric  arteries  with  their  circles,  arcs  and  arcades  by  means  of 
the  arteria  pancreati  co-duodenalis  superior  (a  branch  of  the  hepatic)  and  arteria  duodenalis 
inferior  (a  branch  of  the  superior  mesenteric  artery). 


68  THE  ABDOMINAL  AND  PELVIC  BRAIN 

root  of  the  arteria  mesenterica  superior,  which  it  accompanies  as  a  plexiform 
network  of  nerves  and  ganglia.  Branches  of  right  vagus  joins  the  plexus.  The 
superior  mesenteric  plexus  is  composed  of  thick,  flat,  ganglionated  masses 
(ganglia  mesenterica  superior)  of  oval,  crescentic  or  stellate  form,  which, 
woven  into  thick  sheath,  surrounds  the  superior  mesenteric  artery  and 
accompanies  it  to  the  enteron  (with  the  exception  of  the  duodenum)  and  colon 
(with  the  exception  of  the  left  colon,  sigmoid  and  rectum).  The  plexus 
mesentericus  superior  not  only  arises  from  the  entire  abdominal  brain  but 
from  the  plexus  renalis,  bilateral.  It  also  arises  by  several  cords  from  the 
plexus  aorticus  abdominalis. 

The  plexus  mesentericus  superior  contains  ganglia  relatively  less  in 
number  and  dimension  than  the  plexus  coeliacus. 

A  smaller  portion  of  the  plexus  mesentericus  superior  accompanies  the 
arteria  pancreatico-duodenalis  inferior  proximalward  to  the  duodenum  and 
caput  pancreatica  (rami  pancreatici  duodenales). 

The  greater  portion  courses  on  the  arteria  mesenterica  superior  distal- 
ward  in  the  form  of  a  long  white  closely  fenestrated  plexiform  sheath  to  the 
enteron,  coecum,  right  and  transverse  colon  (rami  enteron  and  rami  colici). 

The  nerves  course  between  the  blades  of  the  mesenteron  and  mesocolon 
partly  closely  adjacent  to  the  artery  and  partly  at  a  distance  from  the  same. 
The  nerves  anastomose  here  and  there  more  irregularly  than  the  arteries  as 
curved  arches.  The  termination  of  the  plexus  mesentericus  superior  is:  (a) 
between  the  longitudinal  and  circular  muscles  of  the  enteron  and  colon — 
ruling  rhythm — (plexus  myentericus  externus — Auerbach's,  Leopold  Auer- 
bach,  German  Anatomist  Prof,  at  Breslau,  1823-1897) ;  (b)  in  the  intestinal 
submucosa — ruling  secretion — (plexus  myentericus  internus — Meissner-Bil- 
roth,  George  Meissner,  1829-1905,  German  Anatomist  Prof,  in  Goettongen. 
Theodor  Bilroth,  German— Prof,  surgery  in  Vienna,  1829-1894,  German 
Surgeon  Prof,  in  Vienna).  The  meshwork  of  the  plexus  myentericus  internus 
is  not  so  regular  nor  the  ganglia  so  large  or  numerous  as  that  of  the  plexus 
myentericus  externus.  On  the  nerve  plexuses  which  accompany  the  vasa 
intestini  tennis  and  on  the  nerve  plexuses  more  distantly  removed  from  the 
vessels,  may  be  found  diminutive  plexuses  and  ganglia.  The  nerves  end  in 
the  wall  of  the  tractus  intestinalis  as  automatic  visceral  ganglia.  Ganglia 
exist  at  the  origin  of  the  arteria  mesenterica  superior  which  endow  the 
enteron  with  several,  three  or  four  rhythms,  daily  (three  meals).  There  may 
be  more  or  less.  The  superior  mesenteric  plexus  is  fan-formed,  is  the  largest 
plexus  in  the  abdomen.  It  accompanies  the  mesenteric  artery  coursing 
dorsal  to  the  pancreas.  The  mesenteric  nerves  are  remarkable  for  strength, 
number,  length  and  thickness  of  their  neuri  lemma.  They  are  placed  in 
contact  with  the  vessels  and  also  at  variable  distances  from  the  same. 
They  course  toward  the  intestine  in  straight  lines  without  emitting  branches. 
At  a  limited  distance  from  the  concave  intestinal  border  they  pass  directly 
toward  the  enteron  and  colon,  or  they  anastomose  with  an  adjacent  nerve  at 
an  angle  or  in  an  arch.  From  the  convexity  of  the  anastomotic  arches  the 
branches  pass  directly  to  supply  the  enteron  and  part  of  the  colon.     There 


THE  NERVES  OF   THE    TRACTUS  INTESTINALIS  69 

is  only  one  series,  row,  of  nerve  arches  in  the  plexus  mesentericus  superior 
regardless  of  the  number  of  series,  rows,  of  arterial  arches  (in  the  vasa 
intestini  tennis).  •  The  simple  nerve  arch  corresponds  to  the  vascular  arch, 
the  most  adjacent  to  the  intestine.  The  superior  mesenteric  plexus  anas- 
tomoses with  the  renal  ganglia,  plexus  mesentericus  inferior  and  ovarica. 
Practically  it  is  a  continuation  of  the  plexus  coeliacus  and  aorticus  abdominis. 

(3)  Plexus  Mesentericus  Inferior  (Unpaired.) 

The  inferior  mesenteric  plexus  consists  of  a  rich  plexiform  network  of 
nerves  and  ganglia  ensheathing  and  accompanying  the  inferior  mesenteric 
artery   to   the   left   colon,    sigmoid   and  rectum   (as  nervi  colici  sinistri  et 


NERVES  OF  THE  HEPATIC  ARTERY  AND  BILIARY  DUCT 

Fig.  15.  Presents  the  copy  of  an  X-ray  of  the  hepatic  artery,  biliary  and  pancreatic  ducts 
which  are  each  richly  ensheathed  by  a  nodular,  plexiform  web  of  nerves.  The  quantity  of 
nerves  may  be  estimated  by  the  number  of  arteries  and  ducts  in  the  liver  and  pancreas.  I, 
Vater's  papilla  at  duodenal  end  of  ductus  chcledochus  communis.  II,  junction  of 
ductus  hepaticus  (III)  and  ductus  cysticus  (IV).  C,  cholcyst,  P,  ductus  pancreaticus,  Sa, 
ductus  pancreaticus  accessorius.  The  black  conduit  coursing  parallel  to  the  biliary  ducts  is 
the  hepatic  artery. 

haemorrhoidales  superiores).  It  arises  from  the  aortic  plexus  and  especially 
from  the  ganglion  located  at  the  origin  of  the  arteria  mesenterica  inferior 
(ganglion  mesenteric  inferior)  as  well  as  from  the  lumbar  lateral  ganglionic 
chain  (plexus  lumbales  aorticus).  The  fenestra  or  meshwork  of  the  inferior 
mesenteric  plexus  are  not  so  compact  or  close  as  that  of  the  superior  mesen- 
teric plexus.  The  nerves  of  this  plexus  form  in  its  course  subordinate 
plexuses,  accompanying  or  lying  between  the  arterial  branches,  and  produce 


70  THE  ABDOMINAL  AND  PELVIC  BRAIN 

curved,  arc  anastomoses.  They  terminate  the  colonic  muscularis  as  Auer- 
bach's  plexus  (rhythm)  and  the  colonic  submucosa  as  Meissner-Bilroth  plexus 
(secretion  and  absorption). 

The  plexus  mesentericus  inferior  arises  from:  (a)  abdominal  brain 
(plexus  mesentericus  superior);  (b)  plexus  aorticus;  (c)  ganglion  mesenter- 
icum  inferior. 

The  plexus  mesentericus  inferior  is  not  only  solidly  and  compactly 
anastomosed  in  all  its  branches,  but  solidly  and  compactly  with  all  other 
abdominal  sympathetic  plexuses.  There  exist  nerve  nodes — ganglia  mesen- 
terica  inferior — along  the  course  of  the  plexus.  At  the  origin  of  the  arteria 
mesenterica  inferior  there  is  located  a  mass  of  nerve  tissue — ganglion  mesen- 
tericum  inferior — which  doubtless  endows  the  faecal  reservoir  (left  colon, 
sigmoid  and  rectum)  with  a  daily  rhythm  for  faecal  evacuation.  The  inferior 
mesenteric  plexus  anastomoses  or  is  connected  with:  (a)  second  lumbar 
ganglion  in  the  lateral  chain;  (b)  plexus  aorticus  abdominalis;  (c)  plexus 
mesentericus  superior;  (d)  plexus  ovaricus;  (e)  plexus  hypogastrics;  (f) 
plexus  haemorrhoidalis  (medius  and  inferior)  from  the  arteria  pudendalis. 
The  plexus  mesentericus  inferior  ends  in  the  colonic  wall  as  automatic 
visceral  ganglia,  Auerbach's  (plexus  myenteric  externus)  and  Bilroth- 
Meissner's  (plexus  myentericus  internus).  The  nerves  of  the  inferior 
mesenteric  plexus  are  remarkable  for  their  tennity,  length  and  general  non- 
branching  state.  The  nerves  of  the  inferior  mesenteric  plexus  are  not  the 
most  numerous  in  the  mesosigmoid.  The  plexus  mesentericus  inferior 
terminates,  like  the  inferior  mesenteric  artery,  by  bifurcating  the  two  divi- 
sions of  this  bifurcation  are  called  the  haemorrhoidal  plexus  superior. 
They  course  bilaterally  cistalward  on  the  rectal  wall  accompanying  two 
lateral  superior  haemorrhoidal,  terminating  partly  in  the  rectum  and  partly 
in  the  plexus  hypogastrics. 

(4)  Plexus  Hcemorrhoidalis  Medius  ct  Inferior  (Paired). 

The  sources  of  the  median  and  inferior  haemorrhoidal  plexuses  are:  (1) 
from  the  dorsal  part  of  the  plexus  hypogastrics;  (2)  the  nerves  accompany- 
ing the  middle  (vaginal)  and  inferior  haemorrhoidal  artery ;  (3)  from  the 
pelvic  brain  (ganglion  cervicale).  The  numerous  nerves  course  bilaterally 
through  the  mesorectum  to  the  rectum.  The  proximal  portion  of  the  two 
haemorrhoidal  plexuses  curve  proximalward  to  anastomose  with  the  plexus 
haemorrhoidalis  superior.  The  distal  portion  passes  distalward  to  supply  the 
rectum  and  vagina.  Small  swellings  may  occur  at  the  nerve  crossings  or 
anastomoses,  however,  ganglia  haemorrhoidalia  are  doubtful  nervus  haemor- 
rhoidalis medius  and  inferior  are  branches  of  the  plexus  pudendus.  The 
nerves  of  the  tractus  intestinalis  are  not  an  independent  system  as  it  is 
solidly  and  compactly  anastomosed  with  all  other  abnormal  systems.  How- 
ever the  haemorrhoidal  nerves  are  a  spur  which  complicates  the  distal  end 
of  the  intestinal  tract  and  separates  the  great  partially  independent  nerves 
of  the  tractus  intestinalis  for  the  rectum.  The  change  is  due  to  the 
distalward  movement  of  parts  of  the  tractus  genitalis  and  tractus  urinarius 


THE   NERVES  OF   THE   TRACTUS  INTESTINALIS 


71 


and  their  function  with  the  rectum.  In  general  I  think  the  older  anato- 
mists with  the  exception  especially  of  Henle  represented  the  nerves  and 
ganglia  supplying  the  tractus  intestinalis  rather  too  rich,  too  abundant. 
Tedious  dissection  will  lessen  the  number  of  nerve  strands  by  eliminating 
white  fibrous  connective  tissue. 

(b)  Physiology  of  the  Nerves  of  the  Tractus  Intestinalis. 

The  physiology  of  the  nerve  plexus  supplying  the  tractus  intestinalis  is 
important  both  theoretic  and  practical.     The  sympathetic  nerves  dominate, 


v/- 


ARTERIES  OF  CECUM  AND  APPENDIX 

Fig.  16.  The  nerves  in  the  important  appendiculo-csecal  region  may  be  estimated  by 
observing  an  illustration  of  the  arteries  of  this  segment  of  the  tractus  intestinalis.  The 
nervus  vasomotorius  richly  ensheaths  the  artery  in  a  plexiform  network. 


rule,  the  intestinal  tract,  hence  it  possesses  a  rhythm,  peristalsis — only 
sympathetic  ganglia  possess  the  power  of  rhythm.  In  the  physiology  of 
organs  the  course  of  nerves  must  be  considered.  First,  the  vagus  (as  cranial 
nerve)  supplies  the  proximal  end  of  the  tractus  intestinalis  as  well  as  its 
appendage;  especially  the  liver  with  numerous  fibres.      The  vagus  aids  to 


72  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

check  rhythm,  especially  of  the  stomach.  Second,  the  spinal  nerves  at  the 
distal  end  of  the  tractus  intestinalis  particularly  the  middle  and  inferior 
hemorrhoidal  nerves  supplying  the  rectum  and  interfering  with  its  rhythm 
or  peristalsis.  The  spinal  nerve  attending  the  rectum  places  it  partially 
under  the  will  in  controlling  to  some  extent  the  evacuation  of  faeces  or  gas. 
Third,  there  is  the  great  splanchnic  nerves,  chief  delegates  in  the  function, 
rhythm  or  peristalsis  of  the  tractus  intestinalis  (median)  especially  in  the 
enteron  or  business  segment.  The  splanchnic  nerves  though  preponder- 
atingly  sympathetic  possess  a  rich  source  in  the  spinal  cord.  Therefore 
though  the  tractus  intestinalis  is  preponderatingly  supplied  with  sympathetic 
nerves  (hence  rhythmic)  it  is  supplied  at  its  proximal  end  by  cranial  nerves 
(vagi)  and  at  its  distal  end  by  spinal  nerves  (hemorrhoidal).  The  general 
function  of  the  tractus  intestinalis  under  the  sympathetic  nerve  is:  (a) 
peristalsis  (rhythm);  (b)  absorption;  (c)  secretion.  Its  object  is  digestion. 
The  business  of  a  physician  is  chiefly  to  aid  in  maintaining  normal  functions, 
i.  e.,  peristalsis,  absorption  and  secretion  in  the  intestinal  tract.  In  the 
general  application  of  the  physiology  of  the  nerves  of  the  tractus  intestinalis 
for  practical  purposes  there  should  be  considered:  (a)  those  of  the  proximal 
end,  stomach  and  appendages;  (b)  the  nerves  supplying  the  medial  region 
(enteron)  and  (c)  the  nerves  supplying  the  distal  end  (colon).  The  great 
sympathetic  nerve  plexuses  accompany  the  arteries. 

(a)    The  Physiology  of  the  Nerves  of  the  Proximal  End  of  the  Tractus  Intes- 
tinalis (Stomach,  Liver,  Spleen  and  Pancreas). 

Since  the  arterial  branches  of  the  coeliac  axis  (hepatic,  gastric  and 
splentic)  are  solidly  and  compactly  anastomosed  at  their  peripheries  by  means 
of  circles  and  arcs  the  three  branches  of  the  coeliac  plexus  which  accompany 
the  hepatic,  gastric  and  splenic  arteries  are  solidly  and  compactly  anas- 
tomosed on  the  arterial  circles  and  arcs.  This  anatomic  fact  solidly  and 
compactly  anastomoses  the  nerve  plexuses  of  the  liver,  stomach,  pancreas 
and  spleen  as  well  as  that  of  the  duodenum  and  pancreas  forming  a  single 
apparatus  thus  inducing  the  nerve  arrangement  of  the  liver,  stomach, 
duodenum,  pancreas  and  spleen  to  act  as  a  unit  or  single  apparatus  with 
the  abdominal  brain  as  a  reflex,  focal  or  reorganizing  center.  In  practice 
this  is  found  true,  e.  g.,  the  irritation  of  a  calculus  in  a  segment  of  the 
biliary  passages  from  inflammation  or  irritation  will  be  transmitted  to  the 
abdominal  brain  as  a  focal  center,  become  reorganized  and  emitted  over  the 
gastric  plexus,  inducing  nausea  or  vomiting,  thus  disordering  the  gastric 
rhythm.  Irritating  food  or  liquid  (alcohol)  in  the  stomach  quickly  disorders 
the  hepatic  rhythm  and  if  gall  stone  be  present  hepatic  colic  is  liable  to  arise. 
Again,  the  introduction  of  food  and  fluid  into  the  stomach  incites  the  rhythm, 
peristalsis  and  secretion  of  the  stomach,  liver,  duodenum  and  pancreas, 
demonstrating  the  anatomic  and  consequently  the  physiologic  connection 
and  anastomoses  of  the  nerve  plexus  apparatus  of  the  stomach,  liver,  duo- 
denum, pancreas  (and  spleen).  The  nerve  apparatus  of  the  viscera  in  the 
proximal  abdomen  is  a  finely  balanced  structure  with  the  abdominal  brain 


THE  NERVES  OF   THE   TRACTUS  INTESTINALIS 


73 


as  a  reorganizing,  focal,  center.  Subjects  with  hepatic  calculus  are  ample 
evidence  of  the  solid  and  compact  anastomoses  of  the  nerves  of  the  stomach 
and  liver,  for  they  avoid  many  kinds  of  food,  as  their  experience  has  taught 
that  stimulating  foods  in  the  stomach  will  excite  hepatic  colic.  The 
rhythm  of  the  proximal  end  of  the  tractus  intestinalis  (stomach)  being 
supplied  by  two  powerful  cranial  nerves  (vagi)  is  the  most  irregular  of  any 
segment  of  the  intestinal  tract. 

(b)     Physiology  of  the  Nerves  Supplying  the  Middle  Region  of  the  Tractus 

Intestinalis  {Enteron). 

The  superior  mesenteric  plexus  is  the  largest  and  richest   sympathetic 
plexus  in  the  body.       It  has  an  extensive  and  an  enormous  surface  area  (a 


AN  X-RAY  OF  THE  DUCTUS  PANCREATICUS  AND  PART  OF  THE  DUCTUS  BILIS 

Fig.  17.  This  illustration  represents  the  ductus  pancreaticus  with  its  lateral  ducts,  all  of 
which  are  richly  ensheathed  in  a  plexiform,  nodular  meshwork  of  nerves.  It  is  an  X-ray  of 
part  of  the  ductus  bilis  and  ductus  pancreaticus  of  a  girl  of  11  years  old.  I  to  II,  ductus  chole- 
dochus  communis.  II  to  III,  ductus  hepaticus.  II  to  IV,  ductus  cysticus.  C,  cholecyst.  It  is 
easy  to  observe  the  segments  of  the  pancreas,  viz. : — caput,  collum,  corpus,  cauda.  In  fact,  this 
beautiful  accurate  illustration  establishes  final  anatomy.  Sa,  ductus  Santorini  functionated 
as  the  celloidin  projected  from  its  exit  duct  during  the  injecting  of  it.  The  proper  eponym 
for  the  pancreatic  secretory  channel  is  the  Hofman-Wirsung  duct.  The  liver  of  this  patient 
was  advanced  in  sarcomatous  disease  but  the  pancreas  appeared  healthy.  P,  ductus  pan- 
creaticus. 

truncate  cone,  the  base  of  which  is  twenty-one  feet;  apex  six  inches; 
height  six  inches — covering  an  area  of  many  square  feet).  The  superior 
mesenteric  plexus  consists  of  a  closely  fenestrated  meshwork  of  powerful 
nerves  and  ganglia  ensheathing  in  a  plexiform  manner  the  superior  mesen- 
teric artery  which  practically  supplies  the  digestive  portion  of  the  tractus 
intestinalis. 


74  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

The  first  factor  in  the  physiology  of  the  superior  mesenteric  plexus  is 
that  it  controls  the  volume  of  blood-supply  of  the  enteron.  It  is  nervus 
vasomotorius  of  the  enteron.  Stimulation  of  the  splanchnics  (which  con- 
stitutes the  major  portion  of  the  superior  mesenteric  plexus)  produces 
hyperemia  of  the  enteron.  The  function  of  the  enteron  depends  on  its  blood 
supply.  The  stimulus  which  induces  necessary  blood  supply  to  the  enteron 
for  digestion  is  the  irritation  that  the  food  produces  on  its  mucosa.  A  full 
enteron  is  hyperaemic,  active  one.  An  empty,  evacuated  enteron  is  an  anaemic, 
quiet  one.  The  three  great  manifest  functions  of  the  superior  mesenteric 
plexus  is  to  produce  in  the  enteron  rhythm,  peristalsis,  secretion  and  absorp- 
tion. There  can  be  little  doubt  that  included  in  the  rhythm  of  the  enteron 
(dependent  on  hyperemia)  is  the  factors  of  secretion  and  absorption.  So 
long  as  enteronic  rhythm  is  not  interfered  or  especially  the  enteronic  (foecal) 
current  is  not  obstructed  the  enteron  performs  its  function  (rhymth,  secretion 
and  absorption.)  However,  as  soon  as  mechanical  obstruction  to  the  enter- 
onic (food)  current  occurs  (as  flexion,  volvulus  stricture)  the  nondrainage 
induces  residual  deposits  resulting  in  accumulation  of  bacteria  and  consequent 
infection.  The  enteron  possesses  a  periodioc  rhythm  about  every  six  hours 
(ingested  meals  and  fluids)  which  enables  absorption  and  secretion  to  com- 
plete itself  and  the  rhythm  to  transport  the  residual  debris  to  the  colon. 

(c)      TJw  PJiysiology  of  the  Nerves  at  the  Distal  End  of  the   Tractiis 

Intestinalis. 

The  physiology  of  the  sympathetic  nerve  at  the  distal  end  of  the  tractus 
intestinalis  is  interfered,  complicated  by  the  addition  of  the  spinal  nerves 
(as  the  proximal  end  is  complicated  by  the  addition  of  the  cranial  nerves — 
vagi).  The  physiology  of  the  distal  end  of  the  tractus  intestinalis  (left 
colon,  sigmoid  and  rectum)  is  chiefly  included  in  the  so-called  hemorrhoidal 
nerves — a  developmental  addition,  an  imposition  on  the  original  markedly 
independent  sympathetic  nervous  system  of  the  intestinal  tract,  through  the 
coalesce  of  the  tractus  intestinalis,  tractus  genitalis  and  tractus  urinarius — 
the  coloaca  has  disappeared  and  its  place  is  supplied  by  a  rectal,  vaginal  and 
urethral  sphincter.  The  haemorrhoidal  nerves  are  a  spur  which  complicates 
anatomically  and  physiologically  the  distal  end  of  the  intestinal  tract  and 
separates  the  great  practically  independent  nerves  (plexus  mesentericus  in- 
ferior) of  the  tractus  intestinalis  from  the  rectum.  The  hemorrhoidal  nerves 
can  not  manifest  definite  action  on  the  tractus  intestinalis  (left  colon,  sigmoid 
and  rectum)  which  I  shall  term  the  faecal  reservoir,  which  has  a  daily  rhythm. 
It  is  practically,  for  local  purpose,  under  the  rule  of  the  inferior  mesenteric 
ganglion.  Numerous  phenomena  of  the  rectum  in  disease,  in  pain,  do  not 
belong  to  the  sympathetic  nerve  but  to  the  spinal  nerves  accompanying  it,  as 
the  sharp  pains  in  the  anal  fissure. 

The  expiratory  moan  resembling  the  bray  of  an  ass  in  rectal  dilatation  is 
explained  by  the  irritation  being  transmitted  over  the  haemorrhoidal  plexuses 
(inferior  medius  and  superior)  to  the  abdominal  brain,  whence  it  may  pass: 
first,  over  the  diaphragmatic  plexus  (right  side)  to  the  right  phrenic  nerve 


THE  NERVES  OF   THE   TRACTUS  INTESTINALIS 


75 


(contracting  the  diaphragm);  second,  over  the  splanchnics  to  the  inferior 
cervical  ganglion,  which  is  connected  to  the  phrenic  by  a  nerve  cord,  whence 
the  route  is  direct  to  the  diaphragm  (inducing  the  diaphragm  to  contract) ; 
third,  the  irritation  from  the  rectal  dilatation  may  pass  over  the  third  and 
fourth  sacral  nerves,  proximalward  of  the  spinal  cord  to  the  cranial  cerebrum 
where  reorganization  and  emission  occurs  over  the  cord  and  phrenic  nerve- 
to  the  diaphragm,  inducing  contraction  and  an  expiratory  moan  or  bray.  The 
disordered  functions  of  the  digestive  canal  are  chiefly  excessive  (diarrhoea, 
colic),  deficient  (constipation),  or  disproportionate  (fermentation).  In  the 
excessive  rhythm  (colic)  or  secretion  of  the  tractus  intestinalis,  we  possess 
effective  remedies,  as  anatomic  and  physiologic  rest;  with  the  holding  of  food 
and  fluids  and  the  administration  of  anodynes  (opiates).  The  treatment 
consists  in  securing  normal  rhythm,  peristalsis,  absorption  and  secretion. 
In  deficient  rhythm  (constipation)  and  secretion  in  the  tractus  intestinalis  we 
possess  effective  remedies  in  the  restoration  of  the  normal  rhythm  and  secre- 
tion as  diet.  Coarse  food,  as  cereals  and  vegetables,  leave  ample  faecal  residue 
to  stimulate  the  colon,  intestine  to  vigorous  peristalsis;  the  evacuation  of 
the  colon  at  regular  intervals;  exercise  and  massage  of  the  abdomen; 
electricity.  It  is  a  known  physiologic  principle  that  regular  habits  of  bowel 
evacuation  daily  will  maintain  the  rhythm  normal,  but  that  neglect  of  regu- 
lar evacuation  will  destroy  the  rhythm;  in  fact,  induce  constipation.  The 
normal  rhythm  of  bowel  evacuation  is  a  delicate  matter  and  mental  disturb- 
ance, change  of  habits,  different  environments,  may  viciate  the  rhythm  of  the 
faecal  reservoir  (left  colon,  sigmoid  and  rectum).  In  disproportionate  peris- 
talsis (colic)  and  secretion  (fermentation),  the  effective  remedy  is  to  regu- 
late the  diet  and  fluid  to  restore  normal  rhythm  and  secretion;  to  introduce 
disinfectants  to  check  fermentation,  as  sulphocarbolates.  It  will  be  observed 
that  the  sympathetic  system  of  the  entire  tractus  intestinalis,  consisting  of 
six  great  plexuses  (nerve  cords  and  ganglia),  viz.:  (a)  gastric;  (b)  hepatic; 
(c)  splenic;  (d)  superior  mesenteric;  (e)  inferior  mesenteric;  (f)  haemor- 
rhoidal,  is  not  only  profoundly  connected  with  the  coeliac  plexus  or  abdomi- 
nal brain,  but  the  five  plexuses  are  all  solidly  and  compactly  anastomosed, 
bound  together  and  also  anastomosed  (connected)  with  all  other  plexuses  of 
the  abdominal  visceral  tracts,  in  order  that  the  chief  potentate — the 
abdominal  brain — may  rule  as  a  single  unit  of  power.  No  conflict  of  power 
arises,  as  all  ganglia  of  the  tractus  intestinalis  are  subordinate  to  the  abdom- 
inal brain — however,  local  rulers,  as  the  ganglion  mesentericum  inferior,  are 
allowed  to  rule,  to  dominate,  with  a  daily  rhythm,  the  faecal  reservoir  (left 
colon,  sigmoid  and  rectum).  The  nerve  plexuses  of  the  various  abdominal 
visceral  tracts  are  anastomosed,  connected,  solidly  and  compactly,  in  order 
to  maintain  a  balanced  system  and  for  local  and  general  physiologic  reports 
to  the  abdominal  brain. 


CHAPTER  VIII. 

NERVES    OF  THE   TRACTUS  URINARIUS  (NERVI  TRACTUS 
URINARIUS).— (A)   ANATOMY,  (B)  PHYSIOLOGY. 

These  are  times  which  try  men's  souls. — Thomas  Paine. 

The  object  of  research  is  not  to  know  the  truth  merely  but  to  discover  something 
that  will  benefit  some  one — relieve  suffering  and  prolong  life. 

(a)    ANATOMY. 

To  the  urinary  tract  pass  nerves  from:  (1)  plexus  suprarenalis,  (2)  plexus 
renalis,  (3)  plexus  ureteris,  (4)  plexus  ovaricus,  (5)  ganglia  lumbales,  (6) 
plexus  communis  arteriae  iliacus,  (7)  ganglia  sacrales,  (8)  plexus  hypogastricus 
(9)  plexus  vesicalis,  (10)  plexus  urethralis,  (11)  plexus  mesentericus  superior, 
(12)  plexus  mesentericus  inferior,  (13)  plexus  arteriae  uterinae,  (14)  plexus 
sacralis  (spinal).  The  above  nerve  plexuses  solidly  and  compactly  anasto- 
mose with  each  other  and  with  all  abdominal  sympathetic  plexuses,  thus  con- 
necting the  tractus  urinarius  intimately  and  profoundly  through  the  nerve 
plexuses  with  all  other  abdominal  viscera. 

(l)  The  Plexus  Suprarenalis  (Paired). 

Bilaterally  from  the  external  border  and  proximal  angle  of  the  abdominal 
brain  depart  from  five  to  eight  coarser  and  finer  nerves  to  supply  the  adrenals. 
These  nerves  are  remarkably  developed  in  infancy.  The  strands  of  the 
suprarenal  plexus  possess  many  small  ganglionic  masses  in  their  course,  and 
at  the  points  of  division.  For  the  small  adrenal  the  nerve  supply  is  enor- 
mous. In  the  plexus  suprarenalis  may  be  found  the  ganglion  suprarenale  or 
nervus  splanchnicus  minores.  The  plexus  suprarenalis  sends  branches  to 
the  plexus  renalis  and  on  the  right  side  also  branches  to  the  plexus 
diaphragmaticus. 

(2)  Plexus  Renalis  {Paired). 

Bilaterally  from  the  external  border  and  distal  lateral  angle  of  the 
abdominal  brain  departs  a  wide  meshed  plexus  of  nerves  along  the  renal 
arteries  to  the  kidneys.  The  renal  plexus  is  composed  of  larger  and  smaller 
ganglia  with  larger  and  smaller  strands  and  it  is  extensively  fenestrated. 
Nerve  branches  from  the  renal  ganglia  course  distalward  on  the  ureter  and 
obliquely  medianward  to  join  the  plexus  aorticus.  The  renal  plexus  is  one 
of  the  richest  in  ganglia  and  strands.  In  fact,  the  renal  plexus  frequently 
appears  as  a  continuation  of  the  cceliac  ganglion.  There  is  a  profound  and 
solid  connection  between  kidney  and  abdominal  brain.  The  renal  plexus 
ensheathes  the  renal  artery  with  a  network  of  ganglia  and  cords  arriving  at 
the  kidney  through  the  hilum.  The  plexus  renalis  receives  strands  from  the 
second  and  third  ganglia  of  the  lumbar  lateral  chain.  The  renal  plexus  is 
connected  with  the  plexus  mesentericus  superior  and  inferior.  The  renal 
plexus  arises  from:  (a),  the  major  splanchnic;  (b),  the  minor  splanchnic;  (c). 

76 


NERVES   OF   THE    TRACT  US   UR1XARIUS 


77 


.IV. 


-AS.V 


ARTERIAL  SUPPLY  OF  THE  TRACTUS  URINARIUS 


Fig.  18.  The  proximal  part  of  the  figure  is  from  corrosion  anatomy  The  nerve  supply 
to  the  tractus  urinarius  is  perhaps  best  remembered  by  recalling  its  blood  supply,  for  the 
sympathetic  nerves  accompany  the  vessels,  especially  the  arteries.  The.  artenes  to  the 
tractus  urinarius  are :  (a)  the  arteria  adrenalis  ;  arteria  renalis ;  arteria  ovarica  (spermatica) 
to  arteria  media  ureteris,  (y)  arteria  uterina,  (z)  the  three  vesical  arteries  observe  each  of 
which  is  accompanied  by  its  plexus  of  nerves  The  tractus  urinarius  is  "^ly  Jeset  wtjivaso. 
motor  nerves.  This  anatomic  fact  is  evident  from  the  violent  symptoms  induced  by  an  ure- 
teral calculus.    See  also  Fig.  %,  for  rich  ganglia  renalia. 


78  THE  ABDOMIXAL  AXD  PELVIC  BRA IX 

the  first  lumbar  ganglion;  (d),  the  cceliac  ganglion;  (e),  plexus  mesentericus 
superior;  (f)  plexus  aorticus — six  sources.  Each  renal  plexus  contains  four 
to  six  ganglia.  A  profound  connection,  anastomosis,  exists  between  the  renal 
plexus  and  plexus  aorticus,  hypogastricus  and  ovaricus — i.  e.,  the  kidney  and 
genitals  are  profoundly  and  solidly  connected  or  anastomosed,  by  nerve  cords 
and  ganglia. 

The  renal  plexus  is  practically  all  sympathetic.  Certain  nerve  nodes — 
ganglia  renalia — remarkable  for  number  and  dimension — are  distributed  in  the 
plexus  renalis.  The  largest  renal  ganglia  lie  on  the  ventral  surface  of  the 
renal  artery,  while  several  smaller  ones  lie  in  the  bifurcations  of  the  arteria 
renalis  and  on  the  distal  and  proximal  border  of  the  renal  artery. 

The  plexus  renalis  receives  some  branches  from  the  plexus  adrenalis  and 
the  plexus  mesentericus  superior.  The  nervus  splanchnicus  minor  supplies 
a  branch  to  the  plexus  renalis  which  is  frequently  strengthened  by  branches 
from  the  two  proximal  ganglia  of  the  lateral  lumbar  chain. 

(-3)  Plexus  Ureteris  {Paired). 
The  ureter  is  supplied  by  a  rich  plexus  of  nerves  from  many  sources,  as 
may  be  observed  from  its  vigorous  and  brusque  rhythm,  resembling  cardiac 
contraction.  The  ureter  consists  of  calcyces,  pelvis  and  ureter  proper,  and 
each  segment  is  supplied  in  a  degree  from  different  areas  of  the  abdominal 
sympathetic,  and  lumbar  and  sacral  chain  of  ganglia,  however,  united  into 
one  unit  of  power  in  order  that  the  ureteral  rhythm  may  be  periodic  and 
orderly  from  proximal  to  distal  end.  The  ureter  is  supplied  by: — (a),  plexus 
renalis;  (b),  plexus  aorticus;  (c),  plexus  ovaricus  (spermaticus);  (d),  lumbar 
lateral  chain;  (e),  sacral  lateral  chain;  (f),  plexus  hypogastricus;  (g),  plexus 
arteria?;  (h),  plexus  mesentericus  superior;  (i),  plexus  mesentericus  inferior; 
(j),  sacral  nerves — ten  sources.  By  the  silver  method  on  fresh  ureters  of  ani- 
mals we  could  demonstrate  rich  plexuses  or  networks  of  nerves  on  the  walls 
of  the  ureter,  with  ganglia  at  the  union  of  junction  of  the  anastomosing 
nerves.  Three  strong  and  important  points  of  rich  anastomoses  of  the  plexus 
ovaricus  and  plexus  uterinus  with  the  plexus  ureteris  occurs  at  (a),  where  the 
ureteris  is  crossed  ventrally  by  the  vasa  ovarica  (spermatica^  which  solidly 
unites  the  ureteral  and  ovarian  (spermatic.)  nerve  plexuses.  This  explains  the 
reflex  pain  of  ureteral  irritation  {e.  g.  calculus)  on  the  ovary  or  testicle  — 
(retraction),  (b),  Where  the  ureter  crosses  dorsally  to  the  arteria  uterina  a 
strong  and  solid  anastomosis  occurs  between  the  plexus  ureteris  and  plexus 
arteriae  uterinae.  Ureteral  irritation  (e.  g.  calculus)  may  be  transmitted  to 
the  uterus  (genitals)  and  bladder,  (c),  The  plexus  ureteris  and  plexus  com- 
munis arteriaeiliacus  solidly  anastomose  at  the  point  where  the  ureter  crosses 
ventrally  to  the  iliac  arteries.  This  explains  the  reflex  pain  in  the  thigh  dur- 
ing ureteral  irritation,  e.  g.%  ureteral  calculus. 

(4)  Plexus  Ovaricus  {Spermaticus — Paired). 
The  ovarian   plexus  arises  from  the  plexus  aorticus,  extending  from  the 
ganglion  cceliacum,  located  at  the  arteria  cceliaca,  to  the  ganglion  hypogastri- 
cum,  located  on  the  promontorium.     Its  chief  origin  is  from  the  ganglion 


NERVES   OF    THE    TRACTUS   URINARIUS 


79 


ovaricum.  Immediately  subsequent  to  its  origin  from  the  plexus  aorticus  it 
presents  about  a  dozen  nerve  strands  which  gradually  coalesce  and  converge 
into  three  main  nerves  trunks,  studded  with  ganglia,  and  accompany  the  vasa 
ovarica  to  the  ovary.  At  the  point  where  the  vasa  ovarica  crosses  ventral  to 
the  ureter  the  accompanying  plexus  ovaricus  forms  a  rich  anastamosis  with 
the  plexus  ureteris.  This  anastamosis  of  the  plexus  ovaricus  with  the  plexus 
ureteris  explains  the  reflex  pains  of  the  irritated  ureter  (ureteritis,  calculus)  in 


NERVES  OF  THE  TRACTUS  URINARIUS— CORROSION  ANATOMY 

Fig.  19.  This  specimen  presents  quite  faithfully  the  circulation,  the  kidney,  calyces  and 
pelvis.  The  two  renal  vascular  blades  I  present  opened  like  a  book.  The  corrosion  was  on 
the  left  kidney  and  the  larger  vascular  blade  is  the  ventral  one.  The  vasomotor  nerves 
accompanying  the  urinary  tract  may  be  estimated  by  the  fact  that  a  rich  plexiform  network 
of  nerves  ensheath  the  arteries,  the  calyces,  pelvis  and  ureter  proper.  When  the  renal  vas- 
cular blades  are  shut  like  a  book  their  thin  edges  come  in  contact,  but  do  not  anastomose. 
The  edges  of  the  vascular  blades  are  what  I  term  the  exsanguinated  renal  zone  of  Hyrtl,  who 
discovered  it  in  1868,  and  we,  at  present,  employ  it  for  incising  the  kidney  to  gain  entrance 
to  the  interior  of  the  calyces  and  pelvis  with  minimum  haemorrhage. 

the  ovary  and  uterus  (testicle  retraction).  The  anastomosis  of  the  plexus 
ovaricus  with  the  plexus  ureteris  solidly  and  compactly  connects  the  ureter 
with  the  entire  length  of  the  plexus  aorticus. 

(5)  Ganglia  Lnmbalcs  {Paired). 
The  two  proximal  lumbar  ganglia  send  branches  to  the  proximal  plexus 
ureteris,  as  well  as  branches  to  the   plexus  renalis  and  plexus  ovaricus,  thus 
supplying  the  proximal  end  of  the  ureter. 


80  THE  ABDOMINAL  AND  PELVIC  BRAIN 

{6)  Plexus  Iliacus  Communis  Arteries  {Paired). 

A  small  artery  springs  from  the  common  iliac  and  supplies  the  lumbar 
spindle  of  the  ureter.  This  solidly  connects  the  plexus  ureteris  with  the 
plexus  of  nerves  that  accompanies  the  iliac  and  femoral  vessels,  accounting 
for  the  pain  in  the  thigh  during  attacks  from  ureteral  calculus  and  ureteritis. 

(7)  Ganglia  Sacrales  {Paired). 

The  proximal  sacral  ganglia  send  branches  to  and  anastomose  with  the 
plexus  ureteris,  thus  intimately  connecting  the  pelvic  ureter  with  all  other 
sympathetic  pelvic  plexuses. 

{8)  Plexus  Hypogastricus  {Paired). 

This  powerful  plexus  sends  several  branches  to  the  pelvic  ureter,  solidly 
anastomosing  the  ureter  with  the  genital  tract. 

{9)  Plexus  Vesicalis  {Paired). 

The  vesical  plexus  consists  of  a  wide  meshed  network  of  nerves  supply- 
ing the  bladder  with  greater  and  smaller  ganglia  studding  the  plexus  at  the 
junction  of  the  anastomosing  nerves.  The  vesical  plexus  arises  from:  (a), 
plexus  hypogastricus;  (b),  ganglion  cervicis  uteri;  (c),  nervi  sacrales;  (d), 
lateral  sacral  chain;  (e),  nerve  plexuses  following  the  course  of  the  three 
vesical  arteries  (superior,  middle  and  inferior)  derived  from  the  hypogastric 
plexus,  (a  large  spinal  nerve  supplies  the  bladder  from  the  third  sacral,  thus 
making  a  mixed  nerve  supply  to  the  bladder).  The  rhythm  of  the  bladder 
(systole  and  diastole)  is  not  so  apparent  as  that  of  some  other  organs,  as  the 
ureter,  heart,  uterus  or  enteron,  being  modified  by  the  interference  of  the 
spinal  nerves. 

The  vesical  plexus  is  a  leash  of  nerves  which  supplies  the  distal  ureter 
and  bladder.  So  far  as  I  can  learn  from  dissection,  it  originates  in  the  pelvic 
brain  (ganglion  cervicale).  The  plexus  vesicalis  solidly  anastomoses  with  all 
other  sympathetic  plexuses  in  the  pelvis. 

{10)  Plexus  Mesentericus  Superior  {Unpaired). 
Sends  some  branches  to  the  proximal  end  of  the  ureter. 
{ll)  Plexus  Mesentericus  Inferior  {Unpaired). 

Sends  several  branches  to  the  ureter.  Nos.  10  and  11  anastomose  the 
ureter  with  the  tractus  intestinalis,  and  hence  when  ureteral  pain  arises  it 
will  be  diffused  through  the  intestines,  and  will  confuse  ureteral  and  intes- 
tinal colic. 

{12)  Plexus  Arteries  Uterincz  {Paired). 

The  uterine  artery  is  accompanied  by  a  strong  nerve  plexus  ensheathing 
it.  At  the  point  where  the  uterine  artery  crosses  ventrally  to  the  uterer  the 
nerve  plexuses  of  the  artery  and  ureter  anastomose  with  each  other.  This 
explains  the  uterine  reflex  pain  during  attacks  of  ureteral  calculus  and 
ureteritis. 


NERVES   OF   THE    TRACTUS   URINARIUS 


81 


(IS)  Plexus  Urethralis  (Paired). 

The  urethral  plexus  is  a  continuation  of  the  vesical  plexus  accompanied 
by  the  sympathetic  nerves  which  arrive  at  the  urethra  on  the  supplying 
blood  vessels. 

The  above  thirteen  plexuses  are  sympathetic,  hence  it  is  evident  that  the 
tractus  urinarius  is  dominated  by  the  sympathetic  nerve  in  its  function 
(rhythm). 


CORROSION   ANATOMY  (Hyrtl's  exsanguinated  renal  zone) 

Fig.  20.  In  this  specimen  of  corrosion  anatomy  the  renal  vascular  blades  (ventral  and 
dorsal)  are  closed  like  a  book.  It  presents  (left  kidney)  on  the  margin  of  the  dorsal  lateral 
surface  the  exsanguinated  zone  of  Hyrtl — the  line  of  minimal  haemorrhage  for  cortical  renal 
incision.  A  rational  method  to  estimate  the  quantity  of  nerves  of  the  tractus  urinarius  is 
to  expose  the  number  and  dimension  of  the  arteries  and  other  tubular  ducts  which  are 
ensheathed  in  a  plexiform  network — a  fenestrated,  nodular,  neural  vagina  of  nerves. 


(14)  Plexus  Sacralis  (Spinal). 

The  sacral  spinal  plexus  sends  nerves  to  the  bladder,  and  hence  gives  rise 
to  a  mixed  nerve  supply.  However,  the  sympathetic  dominates,  as  it  compels 
the  bladder  to  assume  rhythm  (diastole  and  systole).  The  chief  spinal  nerve 
to  the  bladder  arises  from  the  III  sacral,  and  supplies  the  body  of  the  bladder. 


82  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(b)  physiology. 

The  establishment  of  the  nerve  supply  to  the  tractus  urinarius  serves  as  a 
foundation  to  an  understanding  of  its  physiology.  A  complete  nervous  sys- 
tem comprises  (a)  a  peripheral  apparatus,  (b)  a  conducting  cord,  and  (c)  a 
ganglion  cell.  The  object  of  the  nervous  system  is  that  the  peripheral 
apparatus  shall  collect  data  (sensation),  the  conducting  cord  shall  transport 
it,  and  the  nerve  ganglion  shall  reorganize  and  utilize  the  nerve  forces. 

The  collection,  transportation,  and  utilization  of  nerve  forces  from  and 
to  the  tractus  urinarius  is  a  matter  of  vast  importance  in  diagnosis  and 
practice. 

The  function  of  the  tractus  urinarius  is  practically  comprised  in  four  acts, 
viz. : — peristalsis  (rhythm)  secretion,  sensation  and  absorption.  All  visceral 
muscles,  being  under  the  sympathetic  nerves,  must  execute  rhythm,  contract 
and  relax,  or  atrophy.  The  object  of  the  kidney  is  to  secrete  fluid  while  the 
object  of  the  urinary  tract  (ureter,  bladder  and  urethra)  is  to  conduct  a 
stream  of  fluid  to  the  external  body  by  means  of  periodic  rhythmical  move- 
ments. From  ureteral  sensibility,  i.  e.,  from  urine  flowing  on  the  sensitive 
ureteral  mucosa,  every  three  to  five  minutes  a  brusque,  peristaltic  wave 
passes  from  the  proximal  to  the  distal  end  of  the  ureter.  The  vesical  and 
urethral  waves  are  more  irregular,  as  the  bladder  is  practically  a  reservoir. 
The  periodic  ureteral  peristalsis  is  due  to  the  sympathetic  ganglia  located 
within  the  ureteral  wall.  So  long  as  the  ureteral  peristalisis  is  not  interfered 
and  especially  the  ureteral  stream  is  not  obstructed,  the  ureters  perform  their 
periodic  rhythm.  However,  as  soon  as  mechanical  obstruction  to  the  ureteral 
stream  arises  (as  from  flexion,  calculus,  ureteritis  or  stricture)  the  non-drain- 
age induces  residual  deposits  with  resulting  accumulations  of  bacteria, 
whence  the  vicious  circle  occurs  in  the  tractus  urinarius  exactly  similar  to 
the  vicious  circles  arising  from  obstruction  in  the  pylorus  or  the  biliary  ducts. 
The  urinary  ducts  are  independent  organs  conducting  the  urine  to  the 
external  body  by  means  of  rhythmic,  periodic  waves,  regardless  of  the  bodily 
attitude  or  force  of  gravity.  The  kidney  is  a  composite  organ,  consisting  of 
numerous  secretory  organs — malpigian  corpuscles  and  tubuli  uriniferi — and 
no  doubt  these  secrete  rhythmically,  periodically,  though  the  urine  exists 
constantly  in  the  ureteral  calcyces  and  pelvis — that  being  the  accumulative 
results  of  secretion.  The  sympathetic  nerve,  however,  is  a  silent,  ceaseless, 
painless  agent,  unconsciously  increasing  its  function — rhythm,  secretion  and 
absorption — as  food  and  fluid  are  offered. 

It  should  be  remembered  that  nerve  forces  travel  in  the  direction  of  least 
resistance,  i.e.,  a  nerve  plexus  containing  the  greatest  number,  of  nerve 
strands.  It  is  not  multiplication  of  ganglion  cells  that  increases  intelligence, 
it  is  multiplication  of  nerve  connecting  cords  that  facilitates  transmission. 
Hence  in  diseases  of  the  channels  of  the  tractus  urinarius,  as  calculus,  stric- 
ture, ureteral  flexion,  or  ureteritis,  the  organs  connected  with  the  tractus 
urinarius  by  the  greatest  number  of  nerve  strands  will  suffer  the  most 
trauma.     For  example,  in  ureteral  calculus  the  pathologic  irritation   from 


NERVES  OF   THE   TRACTUS   Uh'l.X.lh'WS 


83 


NERVES  OF  THE  TRACTUS   URINARIUS 

Fig.  21.  The  nerves  of  the  urinary  tract  were  dissected  in  this  specimen  under  alcohol. 
The  ureters,  which  I  term  swan-shaped,  were  irregularly  dilated  and  contained  valves  (V), 
SP,  abdominal  brain,  D,  ganglia  renalis  distributed  over  the  dilated  ureteral  pelvis.  C. 
plexus  adrenalis.  The  plexus  ureteris  is  rich  in  plexiform  network.  B,  great  splanchnic, 
Observe  that  the  proximal  ureteral  isthmus  (neck)  lying  in  a  groove  in  the  renal  pole  is  not 
dilated. 


84 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


the  ureter  passes  over  the  giant  renal  plexus  to  the  abdominal  brain,  whence 
reorganization  and  emission  occurs  on  the  plexus  gastricus  to  the  stomach, 
inducing  nausea  or  vomiting.  Again,  the  plexus  ureteris  is  profoundly  con- 
nected or  anastomosed  with  the  plexus  ovaricus  (spermaticus) ;  hence  during 
attacks  of  calculus  the  testicle  suffers  pain  and  is  retracted,  also  the  ovary 
suffers  pain.  In  short,  an  irritation  in  the  tractus  urinarius  will  induce  the 
most  pain  in  the  viscera  possessing  the  plexuses  with  the  greatest  number  of 
nerve  strands. 

The  influence  of  the  plexus  ureteris  is  patent  when  micturition  is  so 
urgent  and  irregular  in  the  presence  of  calculus  or  ureteritis.     The  plexus 


CORROSION  ANATOMY 

Fig.  22.  This  specimen  of  corrosion  anatomy  presents  the  ureteral  calyces,  ureteral 
pelvis,  and  proximal  end  of  ureter  proper  together  with  the  arteria  and  vena  renalis.  All 
segments  except  the  vein  are  ensheathed  in  a  rich  plexiform  network  of  the  nerves  govern- 
ing peristalsis,  absorption,  secretion,  sensation.  When  a  ureteral  calculus  becomes  mobile 
in  the  ureter,  peristalsis  (violent)  and  sensation  (pain)  become  evident. 

vesicalis  is  influential  in  indicating  the  line  of  pain  in  calculus,  and  the  plexus 
urethralis  is  a  continuation  of  it,  localizing  the  pain  in  the  glans  penis  (male) 
and  the  pudendum  and  clitoris  (female).  Hence,  as  regards  pain  in  the 
tractus  urinarius,  it  aids  in  diagnosis  by  manifesting  the  most  prominent 
symptoms  along  the  nerve  plexus  containing  the  greatest  number  of  nerve 
strands,  such  as  the  plexis  renalis  (stomach — vomiting),  plexus  ovaricus  or 
spermaticus  (retraction  of  the  testicle). 

Since  the  nerve  plexuses  of  the  tractus  urinarius  are  solidly  and  compactly 
anastomosed  with  all  the  other  nerve  plexuses  of  the  abdominal  sympathetic, 
the  pain  from  ureteral  disturbances  is  rather  diffuse.  However,  since  the 
nerve  plexuses  of  the  tractus  urinarius  are  extensively  and  profoundly  con- 


NERVES  OF   THE   TR ACTUS   URINARIUS 


85 


nected  with  the  plexuses  of  the  tractus  genitalis,  ureteral  disturbances  are 
more  intensely  reflected  over  the  plexuses  of  the  tractus  genitalis,  c.  g.%  in 
the  nerve  plexus  of  the  ovary,  pudendum,  clitoris  (female),  and  of  the 
testicle,  perineum,  penis  (male). 

As  regards  lithiasis,  the  chief  manifestation   from  the  tractus   urinarius 
is  pathologic  physiology,  that  is,  disordered  function,  rhythm,  absorption. 


RELATION  OF  SPINAL  NERVES   TO  TRACTUS  URINARIUS 

Fig.  23.  Illustrates  the  relation  of  the  spinal  nerves  to  the  ureter,  especially  its  plexus 
lumbalis.  The  ureter  is  intimately  connected  with  the  genito-crural  nerve  (A),  hence  the 
pain  reflected  in  the  thigh  and  scrotum  in  ureteral  colic  and  other  ureteral  diseases.  (2) 
Ileo-inguinal  nerve.     For  illustration  of  ureteral  nerves  and  legend  of  same,  See  fig.  24 

or  secretion.  Hence  the  clue  to  the  local  disorder  must  be  sought  in  the 
nerve  plexuses  suffering  most  intensely,  associated  with  the  tractus  urinarius. 
For  example,  in  calculus  there  may  be  the  reno-uterine  reflex,  the  reno- 
testicular  reflex,  all  indicating  intense  pain  along  the  above-indicated  nerve 
plexuses. 

The  stamping  pain  of  Clement  Lucas  is  where  one  afflicted  with  a 
ureteral  calculus  stands  on  one  foot  and  stamps,  which  places  the  psoas 
muscle  on  a  violent  tension,  and  traumatizes,  massages  the  ureter,  which,  if 


86  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

it  possesses  a  calculus,  will  induce  vigorous  ureteral  peristalsis  and  consequent 
ureteral  pain,  colic.  Jordan  Lloyd's  method  of  inducing  pain  in  the  ureter 
with  calculus,  by  a  blow  on  the  erector  spinas  muscles,  is  simply  another 
process  by  which  the  lumbar  muscles  (especially  the  psoas)  massages  the 
ureter,  exciting  vigorous  ureteral  peristalsis  and  consequent  pain  and  colic. 

The  explanation  of  pain  intensified  in  different  regions  of  the  body 
during  attacks  of  calculus  or  other  diseases  of  the  tractus  urinarius  must  be 
sought  in  the  line  of  the  nerve  plexuses  and  their  anastomoses  with  other 
nerve  plexuses.  For  example,  ureteral  calculus  produces  pain  in  the  plexus 
spermaticus  (pain  and  retraction  of  the  testicle)  because  the  plexus  ureteris 
anastomoses  with  the  plexus  spermaticus  where  the  ureter  is  crossed  ven- 
trally  by  it  (vasa  spermatica).  A  useful  suggestion  for  remembering  the 
nerve  plexus  of  the  tractus  urinarius  is  to  recall  the  arterial  supply,  as  the 
ureteral  nerve  plexuses  accompany  the  arteries  of  the  tractus  urinarius. 

The  function  of  the  tractus  urinarius  is  rhythm  (peristalsis),  absorption, 
sensation,  and  secretion.  The  rhythm  keeps  its  tract  always  full.  It  is  a 
perfect  system  of  waterworks  whose  stop-cocks  or  sphincters  are  always  in 
order  and  on  guard. 


CHAPTER   IX. 

THE  NERVES  OF  THE  GENITAL  TRACT  (NERVI  TRACTUS 
GENITALIS)-(A)  ANATOMY,   (B)  PHYSIOLOGY. 

The  American  government  is  not  in  any  sense  founded  upon  the  Christian 
religion.— Treaty  with  Tripoli  signed  by  President  George  Washington. 

The  appointive  power  of  a  political  party  vitalizes  its  energy  and  locates  its  re- 
sponsibility. 

(a)  anatomy. 

The  origin  of  genital  nerves  are:  I,  nervus  vasomotorius  (sympathetic- 
abdominal  brain);  II,  spinal  cord  (medulla  spinalis),  through  rami  commun- 
icantes  and  rami  nervorum  sacralium  (II,  III,  IV),  cerebrum  (vagi). 

The  three  major  nerve  streams  to  the  tractus  genitalis  are  (a)  the  plexus 
interiliacus  (which  is  a  continuation  of  the  plexus  aorticus)  originating  in  the 
abdominal  brain;  (b)  the  plexus  ovaricus  originating  from  the  whole  plexus 
aorticus;  (c)  plexus  sacralis  spinalis  (rami  nervorum  sacralium — II,  III,  IV). 
The  minor  nerve  streams  to  the  tractus  genitalis  are:  (d)  lateral  lumbar  gan- 
glia (truncus  nervus  lumbales  vasomotorius) ;  (e)  lateral  pelvic  ganglia  (trun- 
cus  nervus  pelvis  vasomotorius);  (f)  nerves  of  the  uterine  artery  (nervi 
arteriae  uterinae) ;  (g)  nerves  of  the  hypogastric  artery  (nervi  arterise  hypo- 
gastrics) richly  demonstrated  in  infant  cadavers.  Also  nerves  of  the  round 
ligament  and  hemorrhoridal  arteries. 

Practically  the  nerves  supplying  the  tractus  genitalis  are  solidly  and 
compactly  anastomosed  connected  with  the  whole  abdominal  vasomotor 
nerves  (sympathetic),  especially  with  the  giant  ganglion  coeliacum— the 
abdominal  brain — the  great  assembling  center  of  the  vasomotorius  abdominale 
or  sympathetic  nerve  plexus.  The  anastomosis  or  connection  of  the  genital 
nerves  to  the  nervus  vasomotorius  (sympathetic)  and  cerebro-spinal  is  vast 
and  profound.  The  order  of  solidarity  or  compactness  of  anastomosis  or  pro- 
fundity of  connection  of  the  vasomotor  nerves  (sympathetic)  to  the  abdom- 
inal viscera  is  the  following,  viz. :  (A)  nervus  vasomotorius  to  the  tract  js 
vascularis  (blood  and  lymph  vessels);  (B)  nervus  vasomotorius  to  tractus 
intestinalis;  (C)  nervus  vasomotorius  to  tractus  genitalis;  (D)  nervus 
vasomotorius  to  tractus  urinarius.  However,  all  the  abdominal  viscera  are 
solidly  and  compactly  anastomosed,  connected  to  the  central  abdominal 
sympathetic  or  vasomotor  nerve  that  no  one  visceral  system  can  become  dis- 
turbed, deranged,  without  affecting  profoundly  all  other  visceral  systems. 
The  derangement  arising  in  the  several  abdominal  visceral  systems  caused  by 
irritation  or  disease  in  any  one  abdominal  visceral  system  is  produced  by 
reflexes,  resulting  in  the  disturbed  common  visceral  function — peristalsis, 
secretion,  absorption,  sensation.  So  far  as  I  am  able  to  observe,  the  reflexes, 
or  irritation   in  the  tractus  genitalis  produces  the  most  profound  and  vast 

87 


88  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

derangement  of  function  in  other  abdominal  viscera  of  any  single  visceral 
system,  e.g.,  irritation,  disease  in  the  tractus  genitalis,  passes  to  the  abdom- 
inal brain  (over  the  plexus  interiliacus  and  plexus  aorticus)  where  it  is  reor- 
ganized and  emitted  to  the  tractus  intestinalis  or  tractus  urinarius,  deranging 
the  common  function  of  peristalsis  (rhythm),  secretion,  sensation  and  absorp- 
tion— causing  deficient,  excessive  or  disproportionate  peristalsis,  secretion  or 
absorption.  The  older  anatomists,  like  the  philosophic  Willis  (1622-1675), 
who  was  the  Sedlian  professor  in  Cambridge,  claimed  that  the  nerves  supplying 
the  tractus  genitalis  arose  from  the  intercostal  nerves,  that  is,  by  means  of  the 
rami  communicantes,  truncus  vasomotorius — lateral  ganglionic  chain  and 
nervi  splanchnici.  This  is  as  true  today  as  in  the  days  of  the  ever-memor- 
able Willis ;  however,  we  ascribe  today  more  to  independent,  more  differen- 
tiation to  the  vasomotor  nerves  (sympathetic)  than  did  Willis.  These 
so-called  intercostal  nerves  (rami  communicantes)  form  a  nervous  center — 
the  abdominal  brain — secondary  to  the  cranial  brain,  which  has  differentiated 
functions  of  the  first  magnitude  as  regards  existence  of  life  itself.  Hence, 
today  we  are  inclined  to  believe  from  experimentation  and  clinical  data  that 
the  chief  origin  of  the  nerves  of  the  tractus  genitalis  is  the  abdominal  brain 
— cerebrum  abdominale,  and  since  this  giant  ganglion  controls  the  vascular 
supply  of  the  abdominal  viscera  it  should  be  termed  cerebrum  vasculare  ab- 
dominale. In  the  consideration  of  the  nerve  supply  of  the  tractus  genitalis  it 
is  favorable  for  convenience  of  description  and  practical  purposes  to  present 
a  major  and  minor  nerve  stream.  The  following  table  presents  in  a  bird's- 
eye  view  the  major  and  minor  nerve  supply  to  the  genital  tract: 

Ma  joy  Nerve  Supply. 

A.  Plexus  interiliacus  (sympathicus). 

B.  Plexus  ovaricus. 

C.  Plexus  sacralis  spinalis  (rami  nervorum  sacralium). 

Minor  Nerve  Supply- 

D.  Lateral  lumbar  ganglia  (truncus  nervus  sympathicus  lumbales). 

E.  Lateral  pelvic  ganglia  (truncus  sympathicus  sacrales). 

F.  Nerves  of  the  uterine  artery  (nervi  arteriae  uterinae). 

G.  Nerves  of  the  hypogastric  artery  (nervi  arteriae  hypogastrics). 

H.     Nerves   of   the   round    ligament   artery    (nervi    arteriae    ligamenti 
rotundi). 

Fig.  24.  An  illustration  of  the  pelvic  brain  (B)  and  the  nerve  supply  in  the  pelvis,  uterus 
and  bladder  and  rectum.  Ut,  uterus  (with  its  plexus  uterinus) ;  Vs,  bladder  (with  its  plexus 
vesicalis)  ;  Ov,  ovary  (with  its  plexus  ovarica)  ;  Od,  oviduct  (with  its  plexus  oviductus)  ;  R, 
rectum  (with  its  plexus  rectalis) ;  GS,  great  sciatic  nerve;  5L,  last  lumbar  nerve;  I,  II,  III, 
IV,  sacral  nerves.  The  nerves  supplying  the  ureter  are  from  (a)  the  I  sacral  ganglia  (see  u 
on  ureter) ;  (b),  hypogastric  plexus  (at  P)  ;  (c)  the  III  sacral  nerve  (at  X)  ;  (d),  pelvic  brain 
(at  B).  The  pelvic  brain (B)  originates  the  plexus  uterinus,  plexus  vaginalis,  plexus  rectal- 
is. Suggestions  for  this  drawing  were  employed  from  Frankenhauser.  H,  interiliac  nerve 
disc  (the  original  visceral  ganglion  located  at  the  aortic  bifurcation — at  present  a  dorso- 
ventrally  flattened  nerve  disc  with  limited  number  of  ganglion  cells).  S.  G.,  the  five  sacral 
ganglia.  16  (a),  right  ureter  at  junction  with  vasa  ovarica.  Note  anastomosis  of  plexus 
ureteris  and  plexus  ovarica  explaining  pain  of  ureteral  calculus  in  testicle  and  in  ovary.  16, 
some  relations  on  left  side.  For  illustrations  of  the  nerves  of  the  tractus  genitalis  see 
previous  figures. 


90  THE  ABDOMINAL  AND  PELVIC  BRAIN 

I.  Nerves  of  the  hemorrhoidal  artery  superior  et  medius  (nerv»  arterise 
hemorrhoidalis  superior  et  medius). 

The  major  nerve  supply  consists  of  (A)  plexus  ovaricus;  (  B)  plexus 
interiliacus  (vasomotorius);  (C)  plexus  sacralis  spinalis  rami  nervorum  sacra- 
lium  (II,  III,  IV). 

(A)   Plexus  Ovaricus. 

Origin.  -According  to  my  dissection  the  main  origin  of  the  ovarian 
nerves  is  from  the  ganglion  ovaricum  proximal,  a  definite  ganglion  of  irregu- 
lar form  and  dimension  located  at  the  origin  of  the  arteria  ovarica  on  the 
aorta.  However,  the  plexus  ovaricus  arises  also  from  the  adjacent  regions 
in  the  plexus  aorticus  both  proximal  and  distal  to  the  ovarian  ganglion, 
especially  it  may  be  noted  that  the  renal  ganglia  contribute  ovarian  nerves. 
Frankenhauser  (1867)  in  one  of  his  tables  marks  the  origin  of  the  ovarian 
nerves  extending  from  the  root  of  the  arteria  renalis  to  the  interiliac  nerve 
disc  located  on  the  sacral  promontory.  He  notes  the  ovarian  nerve  com- 
posed at  the  origin  of  some  twelve  separate  strands,  and  as  they  pass 
distalward  on  the  vasa  ovarica  coalesce  into  three  main  trunks,  studded  with 
ganglia.  In  dissecting  it  will  be  observed  that  the  ganglia  renalia  and 
ganglia  ovarica  are  closely  associated  in  a  solidly  fenestrated  network 
indicating  identical  origin  from  the  Wolffian  body.  I  could  not  discover 
such  an  abundant  ovarian  nerve  supply  neither  from  such  an  extensive  area 
of  the  plexus  aorticus,  as  reported  by  Frankenhauser.  However,  the 
explanation  may  lie  in  the  fact  that  Frankenhauser  dissections  were  from 
non-pregnant  and  infant  genitals.  The  sections  disclosed  large  numbers  of 
nerve  fibres  originating  in  various  regions  from  the  plexus  aorticus,  especially 
the  ganglia  renalia  and  ganglia  ovarica  proximal  and  directing  themselves 
toward  the  vasa  ovarica  coalesce  into  some  three  nerve  trunks.  The  ovarian 
nerves  coerce  with  the  ovarian  vessels,  forming  an  elongated  wide  network 
studded  with  nerve  ganglia  limited  in  number  and  dimension  and  located  at 
the  crossing,  junction  of  the  nerve  strands. 

The  ovarian  nerves  arise  from  the  ganglion  ovaricum  proximal  in  the 
form  of  a  plexus  or  a  leash  which  accompanies  and  ensheaths  the  arteria 
ovarica  to  the  union  with  the  vena,  ovarica,  where  both  the  vein  and  artery 
share  more  equally  the  attention  of  the  ovarian  nerves.  The  plexus  ovaricus 
in  general  arises  from  the  following  ganglia,  viz. :  (a)  ganglion  ovaricum 
(proximal);  (b)  ganglia  renalia;  (c)  ganglion  mesentericum  inferior;  (d) 
ganglia  lumbalis.  The  above  ganglia  are  solidly  and  compactly  connected 
with  the  ganglion  cceliacum. 

{Note. — It  should  be  remembered  that  the  numerous  pains  of  which 
woman  complains  as  being  in  the  ovaries  are  not  located  in  the  ovaries,  but 
reside  in  the  cutaneous  distribution  of  the  ileo  inguinal  and  ileo  hypogastric 
nerves.     It  is  hyperesthesia  of  the  skin). 

The  plexus  ovaricus  arises  from  the  following  plexuses:  (a)  plexus 
aorticus;  (b)  plexus  renalis;  (c)  plexus  mesentericus  superior;  (d)  plexus 
mesentericus   inferior;    (e)    plexus   ureteris    (where  the    vasa   ovarica   cross 


NERVES  OF  TRACTUS  GENITALIS  PREGNANT  ABOUT  THREE  MONTHS 

Fig  25  This  illustration  presents  the  nerves  on  its  genital  vascular  circle  at  about  three 
months  gestation.  The  fundus  of  the  uterus  is  drawn  distalward,  exposing  its  dorsal  surface. 
A,  abdominal  brain.  The  pelvic  brain  is  faintly  represented.  The  plexus  ovancus  is  care- 
fully presented. 


92  THE  ABDOMINAL  AND  PELVIC  BRAIN 

ventral  to  the  ureter  the  plexus  ovaricus  becomes  anastomosed  with  the 
plexus  ureteris,  further  solidly  anastomosing  the  plexus  ovaricus  with  the 
plexus  renalis);  (f)  plexus  interiliacus ;  (g)  the  plexus  ovaricus  receives 
branches  from  the  genito-crural  nerve,  again  solidly  anastomosing  the  plexus 
lumbalis  (spinal)  with  the  plexus  ovaricus  (sympathetic). 

Course. — The  plexus  ovaricus  accompanies  the  vasa  ovarica  in  their 
extended  journey  to  the  pelvis  in  erect  animals  in  the  form  of  sheathed  net- 
work of  nerves  with  extremely  elongated  fenestra.  The  plexus  ovaricus  in 
its  course  is  studded  with  spare  ganglia  of  various  size.  The  nerves  of  the 
plexus,  like  many  other  sympathetic  plexuses,  are  cylindrical — not  flat  like 
those  of  the  plexus  uterinus — and  retain  their  caliber  throughout  their  course. 
Toward  the  distal  end  of  the  vasa  ovarica  the  vein  and  artery  become  more 
branched,  occupying  more  space,  whence  the  plexus  ovaricus  divides  its 
branches  to  accompany  the  additional  vessels.  The  distal  end  of  the  plexus 
ovaricus  divides  and  supplies:  (a)  the  ovary;  (b)  the  oviduct;  (c)  liga- 
mentum  latum;  (d)  the  lateral  border  of  the  uterus;  (e)  it  anastomoses  with 
branches  of  the  plexus  interiliacus. 

(B)  Plexus  Interiliacus  ( Vasomotorius). 

The  interiliac  plexus  extends  from  the  interialic  nerve  disc  to  its  union 
with  the  sacral  nerves  of  the  cervico-vaginal  junction.  It  is  the  major  nerve- 
supply  of  the  genitals.     It  is  elsewhere  described  in  detail. 

(C)  Plexus  Sacralis  Spinalis  (Rami  Nervorum  Sacralium). 

The  second,  third  and  fourth  sacral,  spinal  nerves  emit  branches  (pelvic 
splanchnics)  which  join,  coalesce,  with  the  distal  branches  of  the  interiliac 
plexus  to  form  the  pelvic  brain  (ganglion  cervicale — which  issues  the  white 
rami  communicantes)  practically  the  plexus  uterinus,  plexus  vesicalis,  plexus 
rectalis,  plexus  vaginalis,  plexus  clitoridis,  plexus  pudendalis.  The  spinal 
sacral  nerves  passing  to  the  pelvic  brain  gave  rise  to  the  idea  that  they 
supplied  the  cervix  uteri,  and  that  they  are  sensory  nerves  of  the  uterus.  So 
far  as  I  have  been  able  to  observe,  all  branches  of  the  sacral  spinal  nerves 
first  enter  the  pelvic  brain  before  passing  to  the  uterus  and  vagina.  One 
nerve  from  the  second  sacral  passes  directly  to  the  bladder  without  first  pass- 
ing through  the  pelvic  brain.  The  branches  of  the  sacral  nerve  passing  to 
the  pelvic  brain  vary  in  number,  origin,  arrangement,  length,  and  dimension. 
They  are  the  most  accurately  demonstrated  in  infant  cadavers  preserved  in 
alcohol.  The  blending  or  coalescence  of  the  branches  of  the  sacral  nerves 
(pelvic  splanchnics)  (  I  to  IV)  with  the  distal  branches  of  the  plexus 
interiliacus  (vasomotorius)  results  in  the  pelvic  brain — a  plexiform,  multiple, 
nodular  ganglionic  nerve  mass  located  where  the  rectum  joins  the  cervico- 
vaginal  junction,  and  being  of  irregular  form,  dimension,  weight.  The  pelvic 
brain  is  practically  the  source  of  the  genital  nerves.  The  minor  nerve 
supply  of  the  tractus  genitalis  consists   of  D,  E,  F,  G,  H,  I. 

(D).  The  lateral  lumbar  trunk  ganglia  send  nerves  to  the  plexus 
aorticus  and  plexus  interiliacus. 


THE  NERVES  OF  THE   GENITAL   TRACT 


93 


(E).  The  lateral  pelvic  trunk  ganglia  send  nerves  to  the  genitals  by 
way  of  the  pelvic  brain.     It  sends  nerves  to  the  distal  ureter. 

(F).  The  nerves  accompanying  the  internal  iliac  artery  continue  their 
course  over  the  arteria  uterina  as  the  nervi  arteriae  uterinae. 

(G).  The  nerves  of  the  hypogastric  artery  (nervi  arteriae  hypogastricae) 
carries  larger  numbers  of  nerves  to  the  genitals  in  the  infant.  It  also  emits 
branches  to  the  ureter  and  bladder.  With  atrophy  of  the  hypogastric  artery 
many  nerves  fade  with  the  artery. 

(H).     Nerves   of   the   round   ligament    artery    (nervi  arteriae  ligamenti 


F1C.    I. — PELVIC    BRAIN   OF   AN    INFANT. 


GENITAL  NERVES   OF  INFANT 

Fig.  26.  The  plexus  interiliacus  in  this  infant  extends  from  the  discus  interiliacus  (D) 
to  the  pelvic  brain.  (A)  A  segment  of  the  ureter  (Ur)  is  removed  in  order  to  expose  the 
interiliac  plexus  as  it  is  in  relation  with  the  rectum  (R).  Observe  first  that  the  interiliac 
plexus  receives  contributing  nerves  from  the  I,  II  and  III  sacral  nerves.  Second  observe 
that  the  interiliac  plexus  emits  three  nerve  strands  to  the  uterus  (Ut),  which  do  not  first 
pass  through  the  pelvic  brain.  (A)  Third,  note  the  large  nerve  supply  that  the  rectum 
receives  from  the  plexus  inieriliacus.  This  illustration  I  dissected  under  alcohol  and  it  was 
drawn  by  the  aid  of  a  highly  magnifying  lens.  A  non-developed  pelvic  brain.  The  plexuses 
of  the  pelvic  brain-uterine,  vaginal,  vesical  and  rectal — are  distinct 


94  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

rotundi)  pass  from  the  external  common  iliac  artery  to  join  with  the  plexus 
ovaricus  and  plexus  uterinus. 

(I).  Nerves  of  the  hemorrhoidal  artery  superior  and  medial  (nervi 
arteriae  hemorrhoidalis  superior  et  medius)  emit  nerves  to  the  genitals.  It 
will  be  observed  that  the  major  and  minor  nerve  supply  of  the  genitals  is  so 
extensive,  so  solidly  and  compactly  anastomosed  that  severing  the  genital 
nerves  for  experimentation  is  incompatible  with  life,  and  consequently 
reports  of  such  experiments  are  of  limited  value  only. 

The  Plexuses  of  the  Pelvic  Brain. 

The  pelvic  brain  practically  emits  the  nerves  to  the  pelvic  viscera,  but 
especially  the  plexuses  of  the  genital  tract.     The  table  represents  the  scheme  : 

Plexuses  of  the  Pelvic  Brain. — 1.  Plexus  uterinus.  2.  Plexus  vaginalis. 
3.   Plexus  vesicalis.     4.   Plexus  rectalis. 

1.  Plexus  uterinus  is  emitted  to  the  uterus  from  the  pelvic  brain. 
In  infant  cadavers  I  have  counted  as  many  as  eight  different  strands  of  nerves 
passing  from  the  pelvic  brain  to  the  uterus.  In  the  infant  cadavers  one  can 
observe  several  nerves  passing  from  the  pelvic  brain  over  the  external  border 
of  the  ureter  to  penetrate  finally  the  myometrium.  The  first  proposition  to 
assert  is  that  the  uterus  is  practically  supplied  by  two  plexuses,  viz. :  (a) 
the  plexus  interiliacus  (hypogastricus)  sends  one  (two  or  three)  branches 
directly  to  the  uterus  without  first  entering  the  pelvic  brain ;  (b)  the  plexus 
uterinus,  which  passes  directly  from  the  pelvic  brain  to  the  uterus,  where  it 
anastomoses  with  the  branches  of  the  plexus  interiliacus.  Hence  the  uterus 
is  supplied  by  branches  of  the  plexus  interiliacus  directly  from  the  abdom- 
inal brain  and  the  plexus  uterinus  directly  from  the  pelvic  brain — leaving 
the  abdominal  brain  as  the  chief  ruling  potentate  of  the  abdominal  viscera, 
while  the  pelvic  brain  is  a  subordinate,  local,  ruler  of  the  pelvic  viscera. 
The  plexus  uterinus  accompanies  the  uterine  vessels  in  general  only — not  in 
particular  like  the  intimate  relation  of  the  plexuses  of  the  abdominal  brain 
to  its  visceral  vessels.  The  plexus  uterinus  presents  large,  strong  branches 
to  the  cervix  uteri,  which  is  unusually  rich  in  nerve  supply.  The  order  of 
richness  of  nerve  supply  to  the  uterus  is  (a)  cervix,  luxuriant;  (b)  corpus, 
rich ;  (c)  fundus  uteri,  abundant.  The  form  of  the  nerve  supply  to  the  uterus 
imitates  it,  viz. :  fan-shaped.  In  the  illustrations  of  the  nerves  of  the  uterus 
what  is  presented  is  the  main  superficial  branches  of  the  plexus  interiliacus 
and  plexus  uterinus  which  accompany  the  major  uterine  arteries  the  most 
intimately  along  the  lateral  uterine  borders  (see  figure  3). 

The  branches  from  the  plexus  interiliacus  (one  to  three)  are  distributed  on 
the  dorsal  wall  of  the  cervix,  becoming  distributed  on  the  dorso-lateral 
border  of  the  fundus  uteri,  where  they  anastomose  with  the  branches  of  the 
plexus  ovaricus  at  the  junction  of  the  uterus  and  oviduct,  where  is  located 
(especially  marked  in  infants)  a  ganglion.  The  dorsal  surface  of  the  fundus 
also  receives  numerous  branches  from  the  branches  of  the  plexus  interiliacus. 
Finally  the  branches  directly  from  the  plexus  interiliacus  (which  is  directly 
from  the  abdominal  brain  through  the  plexus  aorticus)  supply  strong,  large 


THE  NERVES  OF   THE   GENITAL   TRACT 


95 


nerves  which  are  richly  distributed  to  the  cervix,  corpus,  fundus,  and  oviduct. 
They  anastomose  solidly  and  compactly  with  the  plexus  ovaricus  and  pl< 
uterinus  from  the  pelvic  brain.  The  plexus  uterinus  — major  nerve  supply  to 
the  uterus — originates  in  the  pelvic  brain.  The  plexus  uterinus,  like  the 
plexus  interiliacus,  approaches  the  uterus  from  the  neck  and  lateral  border. 
This  leash  of  ganglionated  uterine  nerves  from  the  cervico-uterine  ganglion 
in  contradistinction  to  the  branches  of  the  plexus  interiliacus,  supplies  the 


EIC    6.  —  PELVIC    I1RAIN. 


GENITAL  NERVES  OF  ADULT 

Fig.  27.  This  specimen  I  dissected  with  care  under  alcohol.  The  plexus  interiliacus 
extends  from  the  discus  interiliacus  (1)  to  the  pelvic  brain  (A).  Observe:  (1)  Three 
nerve  strands  are  emitted  from  the  interiliac  plexus  to  the  uterus  previous  to  passing 
through  the  pelvic  brain  (A).  (2)  Note  the  contribution  of  the  lateral  sacral  chain  of  ganglia 
and  II,  III  and  IV  sacral  nerves  to  the  plexus  interiliacus.  (3)  Bear  in  mind  the  intimate 
relation  of  the  plexus  interiliacus  to  the  rectum  proximahvard  and  distahvard.  Observe 
the  ganglionated  plexuses  from  the  pelvic  brain — uterine,  vaginal,  vesical,  rectal. 


ventro-lateral  border  of  the  uterus,  and  courses  more  intimately  in  relation 
with  the  uterine  segment  of  the  utero-ovarian  artery.  Many  of  the  large 
nerves  of  this  plexus  are  superficial,  simulating  the  superficial  position  of  the 
artery.  As  the  branches  of  the  plexus  interiliacus  (direct  from  the  abdom- 
inal brain)  richly  supply  the  dorsal  surface  of  the  corpus  and  fundus 
uteri  so  that  the  plexus  uterinus  (directly  from  the  pelvic  brain)  luxuriantly 
supplies  the  ventral  surface  of  the  cervix,  corpus  and  fundus  uteri.    Branches 


96  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

from  the  vesical  ganglia  pass  to  the  plexus  uterinus,  thus  aiding  to  make  the 
uterus  and  bladder  act  clinically  as  one  organ.  The  solidly  anastomosed 
plexuses  of  the  uterine  nerves  continually  increasing  their  area  of  distribu- 
tion and  their  number  of  multiplying  peripheral  branches  as  they  proceed 
toward  the  fundus,  finally  sends  branches  to  anastomose  with  the  plexus 
ovaricus,  especially  at  the  oviductal  junction,  where  lies  a  marked  ganglion. 
This  utero-oviductal  ganglion  appears  to  be  the  nerve  center  from  which 
radiate  nerves  to  the  fundus  uteri  and  distal  oviduct  as  well  as  to  the 
muscular  plates  lying  in  the  ligamentum  latum.  The  entire  uterus  is  sur- 
rounded and  traversed  by  a  closely  woven  network  of  ganglionated  nerve 
plexuses.  The  microscopic  ganglia  are  most  numerous  in  the  region  of  the 
cervix,  especially  adjacent  to  the  pelvic  brain.  The  uterus  is  abundantly 
and  luxuriantly  supplied  by  vasomotor  sympathetic  nerves  from  which,  could 
we  dissolve  the  substance  of  the  uterus,  leaving  the  network,  they  would 
appear  like  a  spider's  web.  It  must  be  remembered  that  the  uterus  is  a 
coalesced  organ,  and  hence  the  adult  nerve  supply  is  a  complex  affair 
resembling  the  adult  circulation,  which  is  most  extraordinarily  demonstrated 
by  corrosion  anatomy. 

2.  Plexus  vaginalis  is  emitted  from  the  pelvic  brain  to  the  vagina. 
The  vaginal  plexus  is  a  rich  leash  or  ganglionated  plexus  of  nerves  which 
surround  the  vagina  like  a  network  of  cords  surrounding  a  rubber  ball.  The 
vaginal  nerve  plexus  and  vaginal  vein  plexus,  both  rich,  complicated  and 
abundant,  intertwine  and  interweave  with  each  other.  The  rich  vaginal 
plexus  is  bedecked  with  numerous  ganglia  at  the  points  of  nerve  convergence. 
The  meshes  of  the  vaginal  plexus,  being  occupied  by  fatty  tissue,  connective 
tissue,  lymph  and  blood  vessels,  its  dissection  is  accompanied  with  difficulty. 
Infant  cadavers  should  be  chosen  to  facilitate  correct  exposure  of  the  finer 
constituents  of  the  vaginal  plexus.  As  the  bladder  is  supplied  by  a  large 
branch  from  the  third  sacral  nerve,  so  the  vagina  is  supplied  from  a  large 
branch  of  the  fourth  sacral  nerve.  The  ganglionated  nerve  cords  from  the 
pelvic  brain  surround  the  vagina  like  a  mighty  network,  ventrally  and 
dorsally.  The  vaginal  plexus  also  emits  many  large  nerves  to  the  rectum 
and  bladder.  The  ventral  vaginal  nerve  leashes  course  proximalward  and 
distalward.  The  larger  ganglia  of  the  vaginal  leash  or  plexus  occur  at  the 
proximal  ventral  vaginal  fornix,  while  on  the  distal  ventral  end  of  the  vagina 
the  ganglia  are  numerous,  but  more  limited  in  dimensions.  The  ganglia  of 
the  dorsal  vaginal  wall  is  limited  in  number.  The  entire  vagina  is  com- 
pletely surrounded  by  a  closely  woven  ganglionated  nerve  network.  These 
perivaginal  and  paravaginal  plexuses  stand  in  intimate  relation  with  the 
pelvic  brain. 

Toward  the  central  longitudinal  axis  of  the  uterus  and  vagina  the  genital 
plexuses  diminish,  simulating  exactly  the  genital  blood  and  lymph  supply. 

3.  Plexus  vesicalis  is  emitted  from  the  pelvic  brain  to  the  bladder. 
The  vesical  plexus  is  of  the  powerful,  rich,  ganglionated  plexuses  or  leashes 
of  the  pelvic  brain.  It  is  solidly  and  compactly  anastomosed  to  the  plexus 
rectalis,  but  especially  to  the  plexus  uterinus,  inducing  the  rectum,  uterus 


TIUl   NERVES  OF   THE   GENITAL   TRACT 


97 


and  bladder  to  act  clinically  or  symptomatically  as  one    apparatus.       For 
description  see  nerves  of  tractus  urinarius. 

4.  Plexus  rectalis  is  emitted  from  the  pelvic  brain  to  the  rectum  as  rich 
network  of  nerves  bedecked  with  ganglia  limited  in  number  and  dimension. 
The  rectal  plexus  emitted  by  the  pelvic  brain  is  a  fine  plexiform  leash 
of  nerves  which  passes  distalward  on  the  lateral  borders  of  the  rectum, 
intimately  blending  with  the  tissues  of  the  rectal  wall.  The  rectum  has  not 
only  a  rich  and  complicated  nerve  supply,  but  it  has  a  mixed  nerve  supply. 
The  following  table  presents  a  general  view  of  a  rectal  nerve  supply: 

Recta!  Nerve  Supply. 

1.  Plexus  hemorrhoidalis  superior  (from  the  arteria  mesenterica 
superior). 


THE  NERVES  OF  THE  TRACTUS  GENITALIS 

Fig.  28.  This  illustration  is  a  dissection  I  made  ten  years  ago  from  a  spare  subject 
The  trunk  of  the  cadaver  I  preserved  in  alcohol  for  six  months.  The  vesical,  rectal,  uterine 
and  vaginal  plexuses  are  evident  as  they  issue  from  the  pelvic  brain,  which  is  an  elongated 
ganglionic  mass. 


2.  Plexus  interiliacus  (from  the  abdominal  brain). 

3.  Plexus   hemorrhoidalis    medius    (accompanying   the    arteria  hemor- 
rhoidalis media). 

4.  Plexus   hemorrhoidalis   inferior    (from    the    arteria    hemorrhoidalis 
inferior  and  plexus  pudendalis  sacralis — mixed  vasomotor  and  spinal  nerves). 

5.  Plexus  rectalis   (from   pelvic  brain — a  powerful,  rich   nerve   plexus 
solidly  anastomosed  to  the  plexus  uterinus  and  vesicalis). 


98  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

6.  Plexus  sacralis  spinalis  (branches  from  the  second,  third  and  fourth 
sacral  nerves). 

7.  Truncus  pelvis  sympathicus  (lateral  sacral  ganglia). 

The  three  great  hemorrhoidal  plexuses  arriving  at  the  rectum  via  the 
three  hemorrhoidal  arteries  invest  it  with  a  network  of  rich  nerve  plexuses. 
A  rich  leash  of  nerves  passes  to  the  rectum  from  the  plexus  interiliacus.  Part 
of  the  branches  of  the  plexus  pass  proximalward  on  the  rectum  to  anastomose 
with  the  plexus  hemorrhoidalis  inferior  (from  the  inferior  mesenteric 
plexus)  while  part  passes  distalward  on  the  rectum,  penetrating  its  coats. 
Some  of  the  branches  of  the  hemorrhoidal  plexus  supply  the  bladder  and 
genitals.  From  this  anatomic  distribution  of  the  hemorrhoidal  plexus — to 
genitals,  rectum  and  bladder — it  is  obvious  that  the  genitals,  rectum  and 
bladder  are  solidly  and  compactly  anastomosed.  Clinical  work  demonstrates 
this  balanced  union  of  organs  in  the  pelvis  through  nerve  connection,  as 
rectal  or  genital  operations  will  induce  inability  to  micturate.  The  plexus 
heemorrhoidalis  medius  (and  inferior)  corresponds  to  the  plexus  pudendalis 
on  the  arteria  pudenda.  For  further  description  of  the  rectal  nerve  supply, 
seetractus  intestinalis.  The  nervous  apparatus  ventral,  lateral  and  dorsal  to 
the  vagina,  that  supplying  the  ureter,  that  coursing  through  the  paramet- 
rium and  perimetrium,  that  supplying  the  bladder,  rectum  and  ureter,  are 
solidly  and  compactly  anastomosed.  They  form  an  inseparable  nerve  plexus 
bedecked  with  ganglia  of  greater  and  lesser  dimensions  surrounding  the  cer- 
vico-vaginal  junction.  The  vast  plexuses  of  the  pelvic  brain,  rich  in  ganglia, 
extend  from  the  cervico-vaginal  junction  distalward  to  the  pelvic  floor  sur- 
rounding with  a  luxuriant  closely  woven  network,  uterus  and  vagina  (tractus 
genitalis),  the  rectum  (distal  tractus  intestinalis),  the  bladder  and  ureter 
(distal  tractus  urinarius). 

(b)     physiology. 

The  physiology  of  the  nerves  of  the  tractus  genitalis  comprises  the 
function  of  the  genital  organs,  which  are  in  order  of  origin:  1,  ovulation; 
2,  absorption;  3,  secretion;  4,  peristalsis  (rhythm);  5,  menstruation;  6, 
gestation;  7,  sensation. 

First  it  should  be  observed  that  the  abdominal  brain  originates  the 
plexus  aorticus,  and  the  plexus  aorticus  gives  origin  to  two  great  nerve 
plexuses,  viz.,  plexus  interiliacus  and  plexus  ovaricus.  The  plexus  inter- 
iliacus, so  far  as  the  genital  tract  is  concerned,  divides  into  two,  i.e.,  one,  the 
larger  branch,  terminates  in  the  pelvic  brain,  while  the  smaller  branch 
terminates  directly  in  the  uterus  without  first  passing  through  the  pelvic 
brain.  The  plexus  ovaricus  arises  from  the  plexus  aorticus  and  terminates 
practically  at  the  ovary;  this  plexus,  however,  proceeds  to  anastomose  with 
the  plexus  uterinus  in  the  ligamentum  latum.  Hence,  a  larger  portion  of 
the  nerves  which  supply  the  genital  tract  arise  in  the  abdominal  brain  and 
pass  to  it  directly  through  the  plexus  interiliacus  and  plexus  ovaricus.  On 
the  other  hand,  a  massive  plexus  (the  uterine  modified  by  the  sacral  spinal 
nerves)   passes    through    the  pelvic   brain  before  it  arrives  at  the  genital 


Spiral  segment  (utcro-ovarian  artery),  i,  2,  3,  4,  5,  6,  7-9,  6-8,  9,  10,  n,  12,  ij,  14,  15. 
Straight  segment  abdominal  aorta,  16.     Common  iliac,  17,  and  internal  iliac,  18 


DIVISIONS  OF  THE  SPIRAL  SEGMENT. 

Pelvic  floor  sapert,  I,  2, 3,  4. 

Uterine  segment,  4, 5,  6. 

Otiducal  segment, 

6,  7-9,  6-8,  9, 

Ovarian  ssgrr-sr.!. 

9,  10,  II,  12. 

Round  ligament 
segment,  13,  14, 15 
Urster.  20,  19 
Vaginal  Ar- 
teries. 25 


.^U 


IMPORTANT  LOCATIONS  IN  THE  SPIRAL  SEGMENT 
Arterio-ureteral  loop,  2.    Cervical 
loop,  2,  3,  4      Distal   arte- 
rio-ureteral    crossing,     2. 
Rami    cervicis,     22. 
Rami     corporis,    23. 
Rami  fundi,  24.  Rami 
oviductus,  31,  32,  33. 

Eisanguinated  utetim 
lones  •*•  central  longi- 
tudinal axis,  <b,  lateral 
cervical  border,  'cj  fun- 
dus, and  <</>  temcj- 
corporeai. 


Chicago,  1902, 


At  the  post  mortem  ths  uterus  was 
injected  in  situ,  also  the  ureters  with 
red  lead  and  starch.  The  specimen 
was  X-rayed  in  Dr.  Harry  Pratt's  I- 
Ray  and  Electro-Therapeutic  Labora- 
tory, doubly  magnified  by  Or.  Wm.  E. 
Holland,  and  followed  as  a  model  by 
Mr.  Zan,  0.  Klopper,  the  artist. 

Arterial  Circulation  of  the  Puerperal  Uterus. 

Four  Hours  Post  Partum?*-Life  Size. 

Illustrating  the  Utero-Ovarian  Vascular  CircleTthe  Circle  of  Byron  Robinson) 

CIRCULATION  OF  THE  PUERPERAL  UTERUS 
Fig  29.     A  reasonable  estimate  of  the  richness  of  the  vasomotor  nerves  (sympathetic) 
to    an    organ    is    made   through    the    number   and    dimensions    of   the   arteries    which   are 
ensheathed  by  a  plexiform,  nodular,  nervous  web.     The  quantity  of  nerve  supply  to  the  ute- 
rus is  vast 


100  THE  ABDOMINAL  AND  PELVIC  BRAIN 

tract.  These  anatomicr-.l  facts  demonstrate  how  solidly  and  compactly  the 
tractus  genitalis  is  anastoi  losed  to  the  whole  abdominal  sympathetic. 
Besides  this  must  be  hel1  in  view  the  modifying  influence  on  the  genital  tract 
of  the  sacral  (spinal)  ne;  .  es  1  hrough  their  coalescence  with  the  distal  end  of 
the  plexus  interiliacus,  i.  c,  I  hrough  the  pelvic  brain. 

Peristalsis  -Rhythm  of  the  Tractus  Genitalis. 

Peristalsis,  or  rhythm,  of  the  genitals,  though  one  of  the  common  func- 
tions of  all  abdominal   viscera   (under  control  of  the  abdominal  brain),  is 
particularly  specialized  in  the  tractus  genitalis— uterus  and  oviducts— to  a 
degree  of  popular  demonstration.       Rhythm  of  the  uterus  to  the  ordinary 
observer  is  its  chief  characteristic  phenomenon.     The  rhythm,  or  peristalsis, 
of  the  uterus  under  the  direct  command  of  the  sympathetic  nerve,    differs 
not,  except  in  degree,  from  the  rhythm  of  other  viscera  under  direct  com- 
mand of  the  sympathetic,  such  as  the  enteron,   colon,  ureter,  spleen,  liver, 
pancreas.       Such  organs  as  the  lungs,  heart,  stomach,  and  bladder,  though 
dominated  by  the  sympathetic,  yet  are  so  powerfully  supplied  by  the  cranial 
nerves   (vagi)  and  the  spinal  nerves  (sacral)  that  their  rhythm  is  modified. 
The   periodic   rhythm    and   stately   peristalsis   of   the    uterus    has    induced 
observers  of  all  time  to  enquire  and  wonder  as  to  its  cause.      That  irritation 
of  the  plexus  interiliacus  and  of  the  plexus  uterinus  is  followed  by  the  rhyth- 
mical movements  of  the  uterus,  is  the  main  testimony  of  a  vast  majority  of 
investigators.       The  myometrium,  the  complicated  muscle  of  the  uterus  in 
general,    is   maintained   and   completely   developed    by    menstruation    and 
gestation,    otherwise   it   would   atrophy.     In   the   uterus  are  located  nerve 
ganglia,  little   brains,    smaller  ganglia— extended  or  transported  from    the 
pelvic  brain  to  the  uterus,  which  I  termed  fifteen  years  ago  automatic  men- 
strual ganglia.       They    are    local    rulers  of  muscle  or  myometrial  rhythm. 
When  the  automatic  menstrual  ganglia  are  periodically  bathed  in  extra  blood 
(which  is  a  stimulant  or  excitant)  they  explode   rhythmically,    the    uterine 
muscle  or  myometrium  assumes  an  active,  vermicular  movement;  thus  the 
myometrium  or  uterine  muscle   is   preserved   from   atrophic    death.     Extra 
absorption  of  the  uterine  glandular  apparatus  is  due  to  the  extra  trauma  of 
the  muscular  bundles  on  the  utricular  glands.      The  myometrium  thrashes, 
massages,  and   whips   the   glands   to    extra   secretory   labors.       Myometrial 
activity  and  glandular  activity  are  concomitant — cause   and   effect.       The 
chain  of  events  is:  extra  blood  to  the  automatic  menstrual  ganglia  induces 
extra  myometrial  rhythm.      Extra  uterine  peristalsis  induces  extra  massage, 
excitation,  to  the  uterine  glands,  which  results  in  extra  secretion.     Therefore, 
be    it    observed   the    dominating    nerve   of   the    uterus— the   sympathetic— 
functionates  as  a  unit— no  conflict,  in  rhythm  which  develops  the  myome- 
trium.    During  gestation  the  automatic  menstrual  ganglia   become   bathed 
with    continual    extra    blood.        Profound    congestion,    progressive    exalted 
engorgement,    produce  extra  nourishment  and  multiply   elements  until  the 
gestating  uterus  is  perhaps  fifty  times  the  dimension  of  the  resting  uterus. 
The  gestating  uterus  is  always  in  motion — rhythm.     One  curious  feature  I 


THE  NERVES  OF   THE   GENITAL   TRACT  101 

have  noted  in  the  arteries  of  gestating  uteri  of  animals  and  man,  and  that  is, 
that  the  uterine  artery  was  enlarged,  hypertrophied,  exactly  from  its  origin  in 
the  internal  iliac.  No  part  of  the  iliac  was  enlarged.  Hence  gestation 
belongs  entirely  to  the  tractus  genitalis,  to  the  utero-ovarian  artery.  The 
function  is  distinct,  does  not  glide  into  any  other  visceral  tract.  The 
sympathetic  nerve  has  through  aeons  of  ages  become  differentiated  to  per- 
form separately  and  distinctly  the  important  functions  of  the  tractus  genitalis. 
The  sympathetic  nerve,  nervus  vasomotorius,  originally  belonged  to  the 
arterial  system.  It  is  differentiated  at  present  to  control  some  veins  and  also 
the  gradually  added  tractus  lymphaticus.  Great  importance  lies  in  the 
tractus  vascularis  and  its  ruler,  nervus  vasomotorius.  The  future  problems, 
especially  as  regards  shock,  must  be  solved  in  the  wide  field  of  the  sympa- 
thetic nerve  and  circulatory  system. 

Besides  rhythm  or  peristalsis  the  nerves  of  the  uterus  preside  over  the 
functions  of  absorption,  secretion,  menstruation,  gestation,  and  sensation  of 
the  uterus,  a  description  of  the  physiology  of  which  space  forbids.  The 
physiology  of  the  oviduct  is  under  the  control  of  the  sympathetic  nerve  and 
we  may  note  the  following  points  in  its  functional  activity: 

The  object  of  the  oviduct  is  transportation — export  and  import  service 
— of  spermatozoa  proximalward  and  of  ova  distalward,  forcing  the  impreg- 
nated ovum  distalward  to  the  uterine  cavity.  The  following  are  the  main 
physiologic  factors  in  oviductal  transportation: 

1.  The  periodic  congestion  of  the  genitals,  stimulation  of  the  automatic 
menstrual  ganglia  by  extra  blood. 

2.  The  cilia  of  the  oviductal  mucosa  whip  continually  toward  the 
uterus  distalward,  not  only  forcing  the  ova  distalward,  but  also  creating  a 
fluid  current. 

3.  The  congestion  induces  the  endosalpinx  to  secrete  a  fluid  which 
makes  the  oviduct  a  canal  to  float  the  ovum  distalward: 

4.  Congestion  induces  continual  oviductal  peristalsis,  which  forces  the 
ova  distalward. 

5.  The  contraction  of  the  muscular  processes  in  the  ligamentum  latum 
enhances  the  peristalsis. 

6.  The  shortening  of  the  fimbria  ovarica  which  induces  the  infundibulum 
to  apply  its  mucous  surface  to  the  ovary,  capturing  the  ovum. 

7.  The  congestion  induces  the  secretion  of  mucus  and  glues  the  infun- 
dibulum on  the  surface  of  the  ovary. 

8.  Intra-abdominal  pressure  aids  the  distal  progress  of  the  ova. 

9.  The  enlarging  of  the  ovum  approaching  the  infundibulum  aids. 

10.  Secretion  of  the  endosalpinx  produces  a  fluid  medium  adjacent  to 
the  proximal  oviductal  end  and  the  cilia  of  the  fimbriae  induce  a  current 
toward  the  abdominal  ostium. 

11.  The  oviduct  has  an  import  (spermatozoa)  and  an  export  (ova)  ser- 
vice. It  is  analogous  to  the  vas  deferens  in  the  male.  The  spermatozoa 
pass  through  the  oviduct  proximalward,  while  the  ova  pass  through  it 
distalward. 


102  THE  ABDOMINAL  AND  PELVIC  BRAIN 

12.  The  oviduct  is  a  temporary  (or  pathologic  permanent)  depot  for 
conception.  The  oviduct  (ampulla)  is  a  physiologic  sporting  ground  for  ova 
and  spermatozoa.  It  has  three  general  physiologic  offices  to  fulfill,  viz. :  (a) 
to  secure  and  transport  the  ovum  (distalward)  to  the  cavity  of  the  uterus; 
(b)  to  conduct  spermatozoa  proximalward;  (c)  to  serve  as  physiologic  tem- 
porary (or  pathologic  permanent)  depot  of  conception.  All  the  physiologic 
statements  in  regard  to  the  ovary  will  be,  that  the  rich  plexus  ovaricus  rules 
ovulation,  but  also,  perhaps,  some  form  of  internal  ovarian  secretion  is 
necessary  for  the  best  normal  corporeal  existence.  The  physiology  of  the 
tractus  genitalis  is  vigorous,  as  it  is  supplied  by  a  luxuriant  system  of  sympa- 
thetic nerves.  With  the  higher  forms  of  differentiated  animals  the 
magnitude  and  influence  of  the  genitalis  increases.  The  higher  the  animal 
the  more  thought  is  applied  to  the  genitals,  the  more  periodic  congestion 
and  permaent  increase  of  nerve  and  blood  supply.  The  intense  attention 
paid  to  sex  in  higher  animals,  such  as  monkey  and  man,  is  a  remarkable 
phenomenon,  and  attention  induces  blood  flow,  congestion.  At  the  bottom 
of  the  sex  lie  ambition,  hope,  and  much  of  the  pride  of  life.  Man's  life 
and  thoughts  are  arranged  around  sex  as  a  center.  Hence  the  genital  nerve 
and  blood  supply  and  consequent  genital  physiology  will  remain  an  increas- 
ing maximum.  For  the  detailed  physiology  noted  in  the  subjects  "Abdominal 
Brain"  and  "Pelvic  Brain"  the  reader  is  referred  to  the  Medical  Age  for 
July,  1905,  and  the  Medical  Review  of  Reviews  for  November,  1905. 


CHAPTER  X. 

NERVES    OF   THE    BLOOD    VESSELS    (NERVI  TRACTUS  VASCU- 
LARIS).—(A)  ANATOMY,   (B)  PHYSIOLOGY. 

Our  most  cherished  hopes  are  frequently  maintained  in  silence. 

Tin-  curfew  tolls  the  knell  of  parting  day— Thomas  Gray  (1116-1111),  professor  of 
modern  history  in  the  University  of  Cambridge,  England. 

(a)  anatomy. 

The  proper  nomenclature  to  apply  to  the  sympathetic  nerves  is  the 
nervus  vasomotorius.  Practically  it  is  a  nerve  belonging  to  the  arteries.  In 
the  anatomy  of  the  nerves  of  the  blood  vessels  two  factors  should  be  consid- 
ered, viz. :  (a)  that  nerves  tend  to  course  with  blood  vessels  as  the  intercostals, 
nerves  in  the  extremities,  nerve  coursing  with  the  aorta  and  its  branches. 
However,  cerebro-spinal  nerves  course  mainly  parallel  with  the  vessels  and 
divide  mainly  as  acute  angles,  while  vasomotor  (sympathetic)  nerves  form  a 
plexiform  network,  a  neural  meshwork,  on  the  walls  of  the  blood  vessel, 
and  are  not  confined  to  acute-angled  dichotomy  but  divide  and  anastomose 
by  angles  of  all  dimensions;  (b)  the  cerebro-spinal  nerves  in  general  do  not 
form  ganglia  in  their  course  along  blood  vessels.  The  vasomotor  nerve 
(sympathetic)  forms  ganglia,  plexiform  nodular  meshwork  on  the  walls  of  the 
arterial  vessels  especially  at  the  bifurcation  or  point  of  exit  of  the  arterial 
divisions.  The  nervus  vasomotorius  courses  along  with  the  blood  vessel  as 
a  nodular  plexus,  a  leash  woven  like  a  web  on  the  vessel  wall.  The  coarser 
or  finer  web-like  anastomotic  meshwork  of  nerves  surrounding  a  vessel  is 
characteristic  of  the  nervus  vasomotorius  (sympathetic).  With  the  develop- 
ment and  differentiation  of  the  animal  life  the  nervus  vasomotorius  becomes 
distributed  in  its  relation  to  blood  vessels,  dislocated,  removed,  transported 
along  projecting  lateral  vessels  from  its  direct  contact  with  the  original  trunk 
vessel.  Excellent  examples  of  removal — dislocation  of  the  vasomotor  nerve 
from  contact  with  its  original  vessel — may  be  observed  in  the  plexus  aorticus, 
and  especially  in  the  instance  of  the  plexus  interiliacus  where  it  is  dislocated 
toward  the  median  line  from  arteria  iliacus  communis.  The  second  signifi- 
cant characteristic  of  the  nervus  vasomotorius  is  its  numerous  nerve  ganglia 
found  attached  to  the  vessel  wall  and  the  location  of  marked  ganglia  at  the 
bifurcation  of  trunk  arteries  as  at  the  aortic  bifurcations.  Ganglia  of  dimen- 
sion also  exist  at  the  origin  or  exit  of  visceral  arteries  from  the  great 
arterial  trunk  as  ganglion  cceliacum  (abdominal  brain)  ganglion  spermaticum, 
ganglion  renalis,  ganglion  arteriae  phrenicae,  ganglion  mesentericum  superior 
et  inferior,  ganglion  cervicale  (pelvic  brain).  These  significant  ganglia 
located  on  the  aorta  at  the  origin  or  exit  of  visceral  vessels,  I  shall  term  the 
aortic  viscerel   ganglia — ganglia   aorticse   viscerales.       The    visceral    aortic 

103 


104  THE  ABDOMINAL  AND  PELVIC  BRAIN 

ganglion  may  have  become  dislocated  from  its  vascular  course  during  devel- 
opment, the  most  typical  example  of  which  is  the  ganglion  cervicale,  which 
was  dislocated,  transported  medianward  from  the  arteria  iliaca  communis  to 
the  lateral  border  of  the  uterus.  In  the  region  of  the  origin  of  the  cceliac  axis, 
the  arterial  tripod,  the  ganglia  have  become  dislocated,  fragmented  and 
removed,  transported  along  adjacently  developed  arteries  as  the  renal,  mes- 
enteric superior  and  inferior.  From  fragmentation  and  transportation  along 
arteries  the  renal  arteries  possess  multiple  ganglia.  In  localities  of  the  tractus 
vascularis  where  the  vascular  parietes  are  of  maximum  thickness,  as  the  myo- 
cardium the  ganglion  cells  collect  in  masses,  known  as  cardiac  ganglia.  We 
thus  have  the  well-known  cardiac  ganglia  of  Ludwig  (1816-1895),  Bidder 
(1810-1892),  Schmidt  (1831-1894),  Remak  (1815-1865).  The  nervus  vasomo- 
toria is  an  automatic  nerve.  Ganglia  located  at  the  anastomosing  points  of 
nerves  accompany  its  network  of  conducting  coils  throughout  the  entire 
course  of  the  artery,  thus  automatically  controlling  each  arterial  segment. 
The  intimate  relations  of  the  nervus  vasomotorius  with  the  great  arterial 
vessels  may  be  sufficiently  observed  in  the  plexus  aorticus  thoracicus,  plexus 
cceliacus  (abdominal  brain)  plexus  aorticus  abdominalis,  plexus  interiliacus, 
plexus  pelvicus  (pelvic  brain).  Ganglia  of  maximum  dimension  are  located 
in  intimate  relation  with  the  entire  course  of  the  aorta.  The  nervus  vas- 
omotorius was  originally  essentially  a  vascular  nerve,  hence  its  name, 
nervus  vasomotorius.  The  nervus  vasomotorius,  vascular  nerve  plexuses, 
begin  in  ganglia  (aortic  visceral  ganglion — ganglion  coeliacum,  spermaticum, 
mesentericum,  renalis,  cervicale),  accompanies  the  arterial  vessels  as  a  plexi- 
form  nodular  meshwork,  a  neural  anastomosed  vascular  sheath,  and  ends  in 
automatic  visceral  ganglia  (Auerbach's,  Meissner's,  automatic  menstrual, 
renal  ureteral,  vesical,  etc.,  etc.),  located  in  the  parenchyma  of  organs. 

In  general  the  dimensions  of  the  ganglia  on  the  arterial  plexuses  corre- 
spond with  the  dimensions  of  the  vascular  channel.  However,  the  renal 
arterial  plexus  is  supplied  with  numerous  ganglia  of  maximum  dimension, 
relatively  greater  in  proportion  than  that  of  the  segments  of  the  arterial 
channels  as  the  myocardium.  The  ganglia  located  on  the  arteries  of  the 
tractus  genitalis  are  relatively  numerous  and  of  large  dimension.  The  original 
great  abdominal  vascular  ganglion  is  that  of  the  coeliac  axis,  from  which 
doubtless  many  adjacent  vascular  ganglia  have  become  fragmented,  and 
transported  on  the  vessels  toward  the  viscera.  Perhaps  the  most  typical 
example  of  this  transportation  of  ganglia  is  the  renal  artery,  on  which  is  dis- 
tributed relatively  numerous  small  and  large  ganglia  throughout  its  entire 
course.  A  peculiar  degenerative  developmental  process  has  occurred  at  the 
bifurcation  of  the  aorta  near  the  sacral  promontory.  According  to  the  general 
rule  there  should  be  a  ganglion  of  large  dimension  located  at  the  bifurcation 
of  the  aorta.  However,  the  nervous  ganglion  located  in  this  region  (which 
I  term  the  interiliac  nerve  disc)  has  not  only  few  ganglion  cells  (some  deny 
the  existence  of  any  ganglion  cell)  but  is  dislocated  distalward  from  the  aortic 
bifurcation  to  the  promontory  of  the  sacrum.  It  is  mainly  a  dorso-ventrally 
flattened  nerve  disc  with  disappearing  ganglion  cells. 


NERVES  OF  THE  BLOOD   VESSELS 


105 


The  vascular  nerve  plexuses  vary  in  dimension  and  fenestration.  The 
meshwork  of  nerves  may  be  coarse  or  fine,  wide  or  narrow.  The  plexus 
aorticus  abdominalis  possesses  ganglia,  cords  and  fenestra  of  maximum 
dimensions.  The  fenestra  are  extensive,  elongated,  formed  by  nerve  cords 
of  maximum  dimension,  on  the  anastomosing  points  of  which  are  distributed 
ganglia  of  maximum  dimension.  The  plexus  renalis  is  a  wide-meshed  net- 
work richly  beset  by  large  ganglia.  It  is  a  plexus  nervus  vasomotorius 
possessing  ganglia,  cords  and  fenestra  of  maximum  dimension.  The  plexus 
mesentericus  superior  possesses  numerous  fine  white  cords  with  relatively 
large  fenestra  and  ganglia  limited  in  number  and  dimension.  This  plexus 
possesses  the  peculiarity  of  the  meshes  or  fenestra  deviating  considerably 
from  the  course  of  the  artery.  The  plexus  hepaticus,  composed  of  branches 
from  the  nervus  vagus  dexter  and  plexus  cceliacus,  surrounds  the  hepatic 
artery  with  strong,  flat  cords  in  the  form  of  a  narrow-meshed  network.    The 


/\ 


CIRCLES,  ARCS  AND  ARCADES  OF  THE  ABDOMINAL  ARTERIES 

Fig.  30.  This  illustration  presents  two  views,  viz. :  (a)  The  arterial  trunks,  arcs,  arcades 
and  circles  of  the  tractus  intestinalis  are  solidly  and  compactly  anastomosed,  connected 
through  blood  currents  and  channels,  (b)  The  sympathetic  nerve  (nervus  vasomotorius) 
accompanies  the  arteries  as  a  plexiform  network,  as  a  nerve  vascular  sheath.  This  cut 
demonstrates  that  the  nerves  of  the  tractus  intestinalis  are  solidly  and  compactly  anasto- 
mosed ;  hence  irritation  on  any  sympathetic  plexus  of  the  tractus  intestinalis  will  affect, 
reflexly,  all  others.  10,  arcs  and  arcades  of  the  cceliac  axis.  6,  7,  8  arcs  and  arcades  of  the 
superior  and  inferior  mesenteric  arteries,  all  of  which  are  anastomosed  united  by  (4),  the 
pancreatico-duodenalis  superior  and  inferior.  The  arterial  arcs,  arcades  and  circles  of  the 
hand  and  utero-ovarian  artery  resemble  those  of  the  tractus  intestinalis.  The  number  and 
dimensions  of  the  arteries  furnish  a  clue  to  the  quantity  of  nerve  supply. 


106  THE  ABDOMINAL  AND  PELVIC  BRAIN 

plexus  lienalis  ensheath  the  arteria  renalis  and  is  bedecked  with  numerous 
ganglia  of  varied  dimension.  Microscopic  and  macroscopic  ganglia  occur  in 
the  vascular  plexuses.  Some  macroscopic  ones  are  constant,  as  the  ganglion 
located  on  the  external  carotid  artery.  Wrisberg's  ganglion  is  situated  in 
the  cardiac  plexus,  notably  the  renal  ganglia  (macroscopic)  are  found  on  the 
plexus  renalis.  In  general  the  vasomotor  nerves,  sympathetic,  form  a  plexi- 
form  nodular  sheath  around  the  blood  vessels  and  enter  with  it  into  the  sub- 
stance of  parenchyma  of  the  organs.  This  arrangement  of  the  nervus 
vasomotorius  induces  many  physicians  to  adopt  the  idea  that  the  nervus 
vasomotorius  originally  and  essentially  belonged  to  the  vascular  system,  and 
is  lost  on  the  coats  of  the  arteries.  The  nervus  vasomotorius  invariably 
accompanies  the  arteries — not  the  veins — the  trunk  of  the  vena  portae  being 
the  only  exception.  The  ganglia  of  the  nervus  vasomotorius  (sympathetic) 
are  connected  with  the  anterior  primary  divisions  of  the  spinal  by  short 
nerve  cords  known  as  rami  communicantes,  which  are  gray  and  white  in  color. 

The  gray  rami  communicantes  arise  in  the  ganglia  of  the  nervus  vasomo- 
torius (sympathetic)  and  pass  to  the  spinal  cord. 

The  zvhite  rami  communicantes  arise  in  the  spinal  cord  and  pass  to  the 
cords  and  ganglia  of  the  nervus  vasomotorius  (sympathetic).  Hence  the 
cerebro-spinal  nerves  and  nervus  vasomotorius  (sympathetic)  are  distinctly 
and  firmly  anastomosed;  however,  like  the  federal,  state,  county  and  city 
government,  possess  many  independent  functions* 

(b)  physiology. 

The  nervus  vasomotorius  consists  of —  (a)  the  lateral  chain  and  its 
ganglia;  (b)  the  nerve  plexuses  and  their  ganglia  accompanying  the  blood 
vessels  from  the  aortic  ganglia  to  the  viscera;  (c)  the  automatic  visceral 
ganglia.  Hence  the  nervus  vasomotorius  of  the  abdomen  consists  of  gang- 
lion cells  and  nerve  cords.  It  must  be  remembered  that  it  is  not  the  number 
of  ganglion  cells  that  designates  the  power  of  a  nervous  system  to  accomplish 
maximum  labor,  but  it  is  particularly  the  number  of  conducting  cords  asso- 
ciating and  connecting  the  ganglion  cells  which  decides  the  superiority  of 
nervous  executive  ability.  The  nervus  vasomotorius  is  peculiarly  rich  in 
conducting  cords,  establishing  rapid  and  frequent  communication  between  its 
ganglion  cells — governing  every  particular  segment  of  the  arterial  channel. 
The  ganglion  cells  of  the  nervus  vasomotorius  are  well  informed  from  the 
rich  association  of  connecting  fiber  transmitting  news  over  many  lines.  To 
illustrate  the  eternal  vigilance  of  the  nervus  vasomotorius  it  need  only  to 
indicate  the  fact  that  the  artery  is  always  on  tension,  that  the  nerve  is  always 
on  guard — awake  or  asleep.  A  ganglion  cell  at  each  end  of  a  conducting 
cord  can  accomplish  more  work  than  the  single  cord  can  transmit.  A  depot 
at  each  end  of  a  railroad  line  can  handle  more  freight  than  a  single  road  can 
transmit.  Increased  number  of  conducting  cords  transmit  increased  informa- 
tion to  the  ganglion  cells.  The  nervus  vasomotorius  is  partially  indepen- 
dent, automatic  in  action.  If  a  frog's  brain  and  cord  be  removed  or  destroyed 
the  visceral   functions  will   proceed  for  a  time.       Circulation,  respiration, 


NERVES  OF  THE  BLOOD   VESSELS 


107 


NERVES  ACCOMPANY  THE  ARTERIES 

Fig.  31.  This  illustration  presents  the  sympathetic  nerves  following  the  arteries.  I 
dissected  this  specimen  (man  40)  with  care,  and  the  artist,  Mr.  Klopper,  sketched  exactly 
from  the  model.  1  and  2,  abdominal  brain.  Pn,  Pneumogastric  nerve;  sp.  Nervus 
Splanchnicus  major.  Ad,  adrenal ;  Dg,  ganglion  diaphragmaticum  ;  Adn,  10  adrenal  nerves, 
(right),  (left),  7.  G.  R.  arteria  renalis  (right  and  left  partially  duplicate).  R.  G.  Ganglia 
renalia  (left).  Ur  ureteral  nerves.  S.  G.  and  5  upper  ganglia  spermatica.  I,  ganglion 
mesentericum  inferior;  X,  ganglionic  coalescence  of  nerves  at  the  vasa  spermatica  and 
ureteral  crossing.  5  (Lower)  ganglionic  coalescence  of  the  nerves  at  the  crossing  of  the 
ureter  and  vasa  iliaca  communis.  ID,  Plexus  interiliacus  (hypogastricus).  ID,  is  the  ne1"ve 
disc  of  the  sacral  promontory.  The  arteries  are  accompanied  by  a  plexiform  nodular 
neural  sheath  encasing  the  vessel. 


108  THE  ABDOMINAL  AND  PELVIC  BRAIN 

digestion,  which  indicates  that  absorption,  secretion  and  peristalsis,  sensation 
remain  intact.  The  functions  manifested  by  the  blood  vessels  are:  (a) 
peristalsis  (rhythm) ;  (b)  absorption ;  (c)  secretion ;  (d)  sensation.  The 
plexiform  nodular  anastomosing  neural  network  ensheathing  the  artery  con- 
trols the  above  four  functions.  The  tractus  vascularis  contracts  and  relaxes 
with  clock-like  regularity.  Sensation  is  important  from  the  fact  that  fluid  in 
the  vascular  channel  is  required  to  produce  normal  vascular  peristalsis. 
Hence  the  rational  idea  in  "visceral  drainage"  is  to  maintain  sufficient  volume 
of  fluid  in  the  vascular  channel  to  stimulate  and  insure  contraction.  It  is  the 
functions  of  the  vascular  plexiform  neural  sheath  that  is  of  peculiar  interest 
to  us.  From  the  fact  that  the  heart  will  continue  its  peristalsis  some  time 
after  removal  indicates  that  the  intramural  cardiac  ganglia  are  automatic. 
That  the  ganglia  are  located  in  the  myocardium  would  indicate  that  the 
nervus  vasomotorius  terminates  in  the  arterial  parietes,  and  hence  the  con- 
traction and  dilatation  of  the  heart  are  analogous  to  the  contractions  and 
dilatations  of  the  arteries,  being  due  to  ganglia  located  in  the  vascular  wall. 
There  is  an  intimate  relation  of  the  blood  vessels  within  the  substance  of 
organs  and  the  automatic  visceral  ganglia.  In  general  the  origin  of  the 
nervus  vasomotorius  is  the  spinal  cord — as  there  lies  the  vasomotor  center, 
yet  ganglia  located  on  the  aorta  {e.  g.,  abdominal  brain)  possess  controlling 
influence. 

Aortic    Visceral  Ganglia — Ganglia  Aortica;   Viscerales- 

I  wish  to  call  attention  in  the  function  of  the  nervus  vasomotorius  to 
the  ganglia  located  on  the  aorta  at  the  exit  of  the  visceral  vessels.  I  have 
termed  them  aortic  visceral  ganglia — ganglia  aorticas  viscerales — because 
they  appear  not  only  to  influence  visceral  vessels,  but  the  function 
of  viscera,  and  to  become,  with  differentiation  and  developmental  processes, 
definitely  associated  with  distinct  individual  visceral  function,  e.  g./\i  one 
examines  systematically  in  man  and  animals  the  arteria  uterina  ovarica 
during  gestation,  and  in  the  resting  state,  a  peculiar  phenomenon  will  be 
observed.  The  uterine  artery  will  be  enlarged,  hypertrophied,  exactly  from 
its  origin  in  the  internal  iliac,  and  the  ovarian  will  be  enlarged,  hypertro- 
phied exactly  from  its  origin  in  the  aorta,  i.  e.,  both  uterine  and  ovarian  arteries 
are  enlarged,  hypertrophied,  from  their  exact  origin  in  the  arterial  trunk. 
Now  the  arteria  uterina  ovarica  possesses  distinct  ganglia  belonging  to  itself 
and  the  genitals.  In  this  case  it  consists  of  ganglion  cervicale,  or  cervical 
ganglion  (pelvic  brain)  dislocated  from  its  original  position  located  at  the 
origin  of  the  uterine  artery.  In  other  words,  through  eons  of  ages  the  ganglia 
at  the  origin  of  the  arteria  uterina  ovarica  have  become  differentiated, 
developed  into  the  power  of  endowing  the  artery  supplying  the  genitals  with 
function — gestation  and  menstruation — which  requires  a  certain  amount  of 
blood.  Again,  at  the  origin  of  the  arteria  mesenterica  inferior  is  located  a 
ganglion  which  irritates  peristalsis  in  the  left  half  of  the  colon — the  faecal 
reservoir  (left  half  of  the  transverse  colon,  left  colon,  sigmoid,  and  rectum) 
— peristalsis  sufficient  for  a  daily  evacuation. 


NERVES  OE  THE  BLOOD   VESSELS 


109 


In  the  tractus  nervosus  accompanying  the  tractus  vascularis  there  are 
differentiations  of  nerve  functions  as,  e.g.,  vasomotor  dilator  nerves  and 
vasomotor  constrictor  nerves.  If  vasomotor  dilator  nerves  be  stimulated 
relaxation  and  rest  of  the  vessels  of  occur.  Hence  these  nerves  have  been 
termed  vaso-inhibatory  nerves,  e.g.,  stimulation  of  the  nervi  eregentes  pro- 


NERVES  OF  THE  BLOOD  VESSELS 

Fig.  32  represents  typical  Vascular  Plexuses,  which  I  dissected  from  a  specimen  taken 
from  a  subject  of  about  fifty  years  of  age.  1  and  2  abdominal  brain  lying  at  the  foot  of 
the  great  abdominal  visceral  arteries.  P.  O .  S.  ganglia  located  at  the  other  visceral 
arteries.  The  nervus  vasomotorius  (sympathetic)  accompanies  the  arteries  in  the  form  of 
a  plexiform,  fenestrated,  neural  sheath. 

ceeding  from  the  plexus  sacralis  (due  to  accidental  trauma  of  the  spinal  cord) 
will  induce  dilatation  of  the  arteries  of  the  penis  with  congestion  of  the 
corpora  cavernosa  and  consequent  partial  erection.  Stimulation  of  the 
spinal  cord  induces  priapism,  i.e.,  pathologic  conditions  of  the  spinal  cord 
may  produce  erection  from  stimulation.      The  vasomotor  constrictor  nerves 


110  THE  ABDOMINAL  AND  PELVIC  BRAIN 

are  in  evidence  when  the  surface  of  the  body  from  fright  or  other  cause 
become  blanched,  pale. 

Anatomically  the  cerebro-spinal  nerves  and  nervus  vasomotorius  is  dis- 
tinctly and  firmly  anastomosed,  connected,  by  the  rami  communicantes, 
however,  like  the  federal,  state,  county  and  city  government,  the  two  systems 
of  nerves  perform  many  independent  local  functions.  Long  ages  of  habitat 
established  this  function. 


CHAPTER  XL 

NERVES  OF  THE  LYMPHATIC  TRACT  (NERVI  TRACTUS 

LYMPHATICUS). 

Since  the  lymphatic  vascular  apparatus  is  an  appendage  of  the  blood 
vascular  apparatus  it  will  be  supplied  and  governed  by  the  nervus  vasomo- 
torius  similarly  to  that  of  the  blood  vascular  system,  hence  its  discussion  will 
be  omitted.  See  Chapter  XXXVIII,  Pathologic  Physiology  of  the  Tractus 
Lymphaticus. 


ill 


CHAPTER   XII. 

ABDOMINAL  BRAIN— CEREBRUM    ABDOMINALE— (A)  ANATOMY; 

(B)  PHYSIOLOGY. 

O,  gentle  sleep,  Nature's  soft  nurse. 

—Shakespeare  (156^-1616). 

Embrouded  u-as  he,  as  it  were  a  mede. 
All  full  of  freshe  flour cs  white  and  rede; 
Singing  he  was,  or  floyting  all  the  day; 
He  was  as  freshe  as  is  tire  moneth  of  May. 

— Description  of  the  Squire  in  Geoffrey  Chaucer  (13b0-U00). 

(a)  anatomy. 

The  abdominal  brain  or  ganglion  coeliacum  has  experienced  multiple 
names  during  the  past  three  centuries. 

Synonyms. — Celiac  ganglion  (ganglion  cceliacum);  solar  plexus  (plexus 
Solaris,  Todd  and  Bowman,  1847);  semilunar  ganglion  (ganglion  semilunare); 
the  great  abdominal  ganglion  (ganglion  abdominale  maximum);  abdom- 
inal brain  (cerebrum  abdominale,  Wrisberg,  1780  [1739-1808]);  the  nervous 
center  of  Willis  (centrum  nervosum  Willisii,  1622-1675);  epigastric  nervous 
center  (centrum  nervosum  epigastricum);  splanchnic  ganglion  (ganglion 
splanchnicum) ;  vascular  abdominal  brain  (cerebrum  abdominale  vasculare); 
epigastric  plexus  (plexus  epigastricus) ;  celiac  plexus  (plexus  cceliacum). 

Some  authors  have  viewed  the  abdominal  brain  or  celiac  ganglion  as 
composed  of  two  parts,  right  and  left,  bilateral  and  paired.  I  shall  consider 
it  as  practically  one  sympathetic  ganglion  or  plexus  anatomically  and  phys- 
iologically, and  term  it  the  abdominal  brain — the  celiac  ganglion,  a 
coalesced,  vascular,  visceral  brain,  unpaired,  existing  at  the  origin  of  the 
celiac,  superior  mesenteric,  and  renal  arteries  (major  visceral  arteries). 

The  arrangement  of  the  abdominal  brain  consists  of:  (a)  afferent  or 
centripetal  nerves  (entering  or  contributing  nerves  from  the  cerebrum, 
spinal  cord,  or  sympathetic) ;  (b)  efferent  or  centrifugal  nerves  (distributing 
or  visceral).  The  afferent  nerves  enter  chiefly  on  the  proximal  and  lateral 
borders,  while  the  efferent  nerves  radiate  from  all  regions  of  the  abdominal 
brain — hence  solar  plexus.  There  is  no  relation  between  the  number  and 
dimension  of  afferent  and  efferent  nerves  of  the  abdominal  brain. 

Fig.  33.  An  illustration  of  the  sympathetic  nerve  with  abdominal  brain.  In  this 
specimen  the  ureters  (calyces,  pelvis,  and  ureter  proper)  were  dilated  to  the  dimensions  of 
an  index-finger,  the  channel  of  the  tractus  urinarius  presenting  no  sphincters  intact.  This 
subject  possessed  a  typical  abdominal  brain  (1  and  2)  as  well  as  a  well-marked  pelvic  brain 
(B).  The  ganglion  hypogastricum  (H)  is  well  marked.  This  illustration  presents  fairly  well 
the  abdominal  sympathetic  with  their  varied  anastomoses.  The  great  ganglionic  masses  of 
the  abdomen  (1  and  2)  and  pelvis  (B)  are  evident.  It  presents  a  general  outline  of  its 
nervous  vasomotorius.  I  secured  this  specimen  from  an  autopsy  through  the  courtesy  of 
Drs.  W.  A.  Evans  and  O'Byrne. 

112 


ill 


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Fig.  33.  ABDOMINAL  BRAIN. 


114  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(a)  Afferent  nerves.  The  afferent  or  contributing  nerves  composing  the 
abdominal  brain  are:  (sympathetic),  (1)  plexus  aorticus  thoracicus 
(unpaired);  (2)  nervus  splanchnicus  (paired),  constituting  the  most  essential 
portion  of  the  abdominal  brain ;  (3)  branches  from  the  two  proximal  lumbar 
ganglia  (paired):  (cerebrospinal)  I,  nervus  vagus  (paired),  especially  the 
right;  II,  nervus  phrenicus  (paired),  especially  the  right.  The  abdominal 
brain  consists  of  the  coalesced  termination  of  the  above  (1,  2,  3,  I,  II)  five 
nerve  apparatus.  The  abdominal  brain  is  the  major  assembling  center  of 
the  abdominal  sympathetic. 

(b)  The  efferent  nerves.  The  efferent,  visceral,  or  distributing  nerves  of 
the  abdominal  brain  of  various  caliber  radiate  in  a  plexiform  arterial  sheath 
to  every  abdominal  viscus,  viz.,  to  the  tractus  intestinalis  and  its  appendages: 
plexus  hepaticus,  lienalis,  gastricus,  mesentericus  superior,  mesentericus 
inferior,  haemorrhoidalis;  to  the  tractus  urinarius :  plexus  suprarenalis, 
renalis,  ureteris,  vesicalis,  urethralis;  to  the  tractus  genitalis:  plexus 
ovaricus,  hypogastricus  (pelvic  brain),  plexus  uterinus  pudendalis  vaginalis; 
to  the  tractus  vascularis  and  tractus  lymphaticus.  The  abdominal  brain 
emits  plexiform  nerves  and  ganglia  fixed  in  connective  tissue  sheaths  which 
intimately  encase  the  vascular  tubes.  The  nerves  emitted  from  the  abdo- 
minal brain  are  gray  or  white  in  color,  limited  in  diameter,  plexiform  in 
arrangement,  resist  tension  on  account  of  the  thick  fibrous  neurilemma,  and 
ganglia  are  liable  to  occur  at  their  points  of  crossing  or  anastomosis.  The 
radiating,  efferent  nerves  of  the  abdominal  brain  accompany  the  arteries 
arranged  in  a  plexiform  sheath  or  network.  They  do  not  accompany  the 
veins — the  trunk  of  the  vena  portas  being  the  only  exception. 

I.  Position:     Holotopy  (relation  to  general  body). 

The  abdominal  brain  is  located  at  the  proximal  end  of  the  abdominal 
cavity  immediately  distal  to  the  diaphragm.  It  is  situated  medially,  extra- 
peritoneally,  and  is  practically  bilaterally  symmetrical. 

II.  Skeletopy  (relation  to  osseous  skeleton). 

The  abdominal  brain  corresponds  to  the  level  of  the  first  lumbar  verte- 
bra, on  its  ventral  surface. 

III.  Syntopy  (relation  to  adjacent  organs). 

The  syntopic  relations  of  the  abdominal  brain  are  intimate  and  profound 
connections  with  vascular  and  visceral  organs.  It  surrounds  the  roots  of 
the  celiac,  superior  mesenteric,  and  renal  arteries  like  a  collar  or  fenestrated 
sheath.  It  is  located  extraperitoneally,  on  the  ventral  surface  of  the  aorta 
and  crura  of  the  diaphragm.  It  is  situated  immediately  distal  to  the  hiatus 
aorticus  of  the  diaphragm.  It  lies  between  the  diaphragmatic  and  renal 
arteries.  Right  and  left  it  projects  against  the  capsules  of  the  adrenals.  It 
is  located  between  the  proximal  renal  poles.  It  lies  partly  dorsal  to  the 
corpus  pancreaticus  and  stomach.  Its  right  half  lies  between  the  right 
crus  of  the  diaphragm  and  the  vena  cava.  Practically  the  abdominal  brain 
is  lodged  in  the  space  bounded  bilaterally  by  the  adrenals  and  proximal  renal 
poles;  proximally  by  a  line  drawn  transversely  from  the  proximal  point  of 
one  adrenal  to  that  of  the  other;  distally  by  the  renal  arteries.     The  situa- 


THE  ABDOMINAL  BRAIN  115 

tion  of  the  abdominal  brain  is  included  within  the  space  of  origin  of  the  celiac 
and  renal  arteries— some  two  inches. 

IV.   Idiotopy  (relation  of  component  segments). 

The  component  parts  of  the  abdominal  brain  are  from  proximal  to  distal 
end  in  order,  viz.:  (a)  The  projecting  ganglia  of  the  origin  of  the  diaphrag- 
matic nerves  located  on  the  proximal  border — conical  elevations  or  bulb  of 
the  brain  itself;  (b)  the  semilunar  ganglia,  the  essential  material  in  form 
and  dimension  of  the  abdominal  brain,  constituting  its  major  central  segment; 
(c)  the  renal  ganglia,  located  generally  at  the  origin  of  the  renal  arteries,  are 
practically  constant,  however  varying  in  location,  form,  and  dimension. 
The  segments  proximodistally  are  compactly  and  solidly  united  by  ganglionic 
masses,  flattened  commissures,  and  nerve  cords  along  the  lateral  borders  of 
the  aorta.  The  segments  laterally,  i.e.,  the  right  half  and  left  half,  are 
united  transversely  around  the  roots  of  the  celiac,  superior  mesenteric,  and 
renal  arteries  by  ganglionic  arches,  flattened  commissures,  and  nerve  cords 
extending  transversely  from  the  right  to  left  half  of  the  brain. 

Dimensions. — The  abdominal  brain  or  celiac  ganglion  is  the  largest  and 
richest  ganglion  of  the  sympathetic  nerve.  Hence  from  a  preponderating 
aggregation  of  nerve  cells  it  becomes  the  ruling  potentate  of  the  viscera. 
The  left  half  is  more  compact,  greater  in  dorsoventral  diameter,  thicker,  less 
fenestrated,  and  possesses  more  definite  regular  borders  than  the  right; 
however,  the  right  half  is  greater  in  surface  area.  Its  diameters  are:  (a) 
transverse  about  V/2  inches;  (b)  proximodistal  V/i  inches;  (c)  dorsoventral 
about  \  inch.  The  dimensions  of  the  abdominal  brain  practically  correspond 
with  the  space  bounded  bilaterally  by  the  two  adrenals  and  the  two  proximal 
renal  poles;  distally  by  the  two  renal  arteries;  proximally  by  the  diaphrag- 
matic arteries,  or  a  line  drawn  transversely  from  the  proximal  end  of  one 
adrenal  to  that  of  the  other.  Its  surface  dimensions  vary  extremely  on 
account  of  the  indefinite  coalescence,  interpolation,  distribution,  dislocation 
of  ganglion  or  by  transportation  along  visceral  vessels. 

The  Form. — The  form  of  the  abdominal  brain  is  variable;  however,  in 
general  it  is  quadrilateral.  It  may  present  a  half-moon  or  horseshoe  shape, 
or  a  ring  surrounding  the  celiac  axis  and  superior  mesenteric  artery.  It  may 
also  be  represented  by  a  single  broad  fenestrated  ganglionated  plate  which 
covers  the  ventral  surface  of  the  aorta  adjacent  to  the  celiac  axis,  and 
occupies  the  space  between  the  adrenals  and  proximal  renal  poles.  The 
left  half  may  resemble  a  bean,  a  retort  in  compact  form,  while  the  right  half 
is  more  quadrilateral,  flattened  (from  compression  of  the  vena  cava),  and 
irregular  in  contour.  The  form  has  changed  by  development  from  coales- 
cence, interpolation,  isolation,  and  transportation  of  ganglia  along  visceral 
vessels,  the  vertebral  column  and  ribs. 

The  Borders.  —The  borders  of  the  abdominal  brain  (margo  cerebri 
abdominalis)  are  four,  viz. :  proximal,  distal,  and  two  lateral,  (a)  The 
proximal  border  presents  three  factors  of  interest.  The  first  is  the  concave 
horseshoe-like  depression  made  in  it  by  the  celiac  axis  and  the  surrounding 
of  the  vessel  like  a  collar  by  nerve  cords  and  ganglia  in  a  connective  tissue 


116  THE  ABDOMINAL  AND  PELVIC  BRAIN 

sheath.  The  other  two  factors  are  the  cone-like  projections  of  a  portion  of 
the  brain  which  emits  bilaterally  the  nervus  (plexus)  diaphragmaticus.  The 
proximal  border  receives  the  continuation  of  the  nerves  of  plexus  aorticus 
thoracalis  as  well  as  the  termination  of  the  right  vagus  (cranial),  and  also 
communication  may  occur  with  the  right  nervus  phrenicus.  The  proximal 
border  is  generally  blunt  and  rounded.  Practically  the  plexus  gastricus  is 
emitted  from  its  proximal  border.  (b)  The  lateral  border  (left)  presents 
quite  an  uneven  line,  with  irregular  projections  for  efferent  nerves,  chiefly 
destined  to  the  adrenals  and  kidneys,  and  for  afferent  nerves,  especially 
the  major  splanchnic.  The  main  projections  along  its  border  are  those  pro- 
duced by  the  ganglion  splanchnicum  and  ganglia  renalia.  (c)  (right).  The 
lateral  border  is  generally  an  irregular  line  caused  by  the  irregular  size  and 
location  of  the  ganglion  splanchnicum  and  ganglion  adrenalis.  The  lateral 
borders  receive  (afferent)  nerves  (splanchnic  major)  and  emit  (efferent)  nerves 
(plexus  adrenalis  and  plexus  renalis).  (d)  The  distal  border  is  bounded  by 
the  arteria  renalia — practically  an  even  line.  It  emits  or  distributes  efferent 
nerves  of  various  caliber  to  the  abdominal  visceral  tracts. 

Fenestra;. — The  compact  left  half  of  the  abdominal  brain  may  be 
limitedly  perforated,  while  the  widely  meshed  right  half  is  considerably 
fenestrated  with  larger  and  smaller,  irregular-shaped  apertures  adding 
unevenness  to  the  surface.  The  fenestras  possess  sloping,  smooth,  irregular 
contoured  edges  and  are  occupied  with  connective  tissue,  blood  and  lymph 
vessels,  glands,  and  areolar  tissue.  The  chief  central  fenestras  are  produced 
by  the  celiac  axis  and  superior  mesenteric  artery.  The  left  half  of  the  brain 
generally  has  one  major  fenestra  due  to  a  blood-vessel  springing  from  the 
aorta.  The  right  half  of  the  brain  possesses  some  three  definite  apertures, 
or  fenestras,  and  several  irregular  large  ones.  In  general  the  right  half 
possesses  two  kinds  of  fenestras,  viz. :  (smaller)  those  in  the  more  solid 
median  division  of  the  brain,  and  (larger)  those  in  the  lateral,  more  widely 
meshed  portion.  The  splanchnic  ganglia,  located  at  the  termination  of  the 
splanchnic  nerves,  are  situated  in  the  middle  of  the  celiac  plexus  and 
represent  the  major  ganglionic  masses. 

The  Surfaces. — The  surfaces  of  the  abdominal  brain  (facies  cerebri 
abdominis)  consist  of  two,  viz. :  (a)  the  ventral,  (b)  the  dorsal.  The  ven- 
tral surface  is  uneven,  from  coalescence  of  smaller  and  larger  ganglia, 
irregular  coalescence,  compression  of  adjacent  viscera  (as  the  inferior  vena 
cava),  or  dislocation  of  ganglia  by  transportation  along  vessels.  The 
ventral  surface  is  convex  from  the  dorsal  compression  of  the  aorta  and  crura 
diaphragmatica.  The  ventral  surface  receives  (afferent)  and  emits  (efferent) 
nerves;  also  may  be  observed  nerve  loops  which  originate  and  insert  them- 
selves on  the  ventral  surface.  From  the  ventral  surface  pass  the  nerves  to 
the  adrenal,  pancreas,  and  plexus  renalis — in  fact,  the  nerve  plexuses 
accompanying  the  branches  of  the  celiac  axis  and  many  of  the  plexus  mesen- 
tericus  superior  from  the  ventral  surface.  The  surface  is  solidly  bound  by 
connective  tissue  to  adjacent  structures.  The  ventral  surface  of  the  left 
half  of  the  abdominal  brain  is  concave  from  the  contact  pressure  of  the 
cylindrical  aorta  and  crura  diaphragmatica. 


ABDOMINAL  BRAIN. 

Fig.  34.  This  illustration  is  drawn  from  a  specimen  I  secured  at  an  autopsy  through  the 
courtesy  of  Drs.  Evans  and  O'Byrne.  The  right  kidney  was  dislocated,  resting  on  the  right 
common  iliac  artery,  with  its  pelvis  (P)  and  hilum  facing  ventralward.  The  adrenal  (Ad.) 
remained  in  situ.  It  was  a  congenital  renal  dislocation,  and  was  accompanied  with  con- 
genital malformations  in  the  sympathetic  nerve,  or  nervus  vasomotorius.  1  and  2  is  the 
abdominal  brain.  It  sends  five  branches  to  the  adrenal  from  the  right  half  (2).  Though 
the  sympathetic  system  is  malformed,  yet  the  principal  rules  as  regards  the  sympathetic 
ganglia  still  prevail,  viz.,  ganglia  exist  at  the  origin  of  abdominal  visceral  vessels,  e.g.,  3, 
at  the  origin  of  the  inferior  mesenteric  artery ;  at  the  root  of  the  renal  vessels,  HP  is  no 
doubt  the  ganglion  originally  at  the  root  of  the  common  iliacs  (coalesced).  In  this 
specimen  the  right  ureter  was  5  inches  in  length,  while  the  left  was  11^4.  This  specimen 
demonstrates  that  the  abdominal  brain  is  located  at  the  origin  of  the  renal,  celiac,  and 
superior  mesenteric  vessels — i.e.,  it  is  a  vascular  brain  (cerebrum  vasomotorius). 


118  THE  ABDOMINAL  AND  PELVIC  BRAIN 

The  fenestra:  or  perforations  of  the  dorsal  surface  correspond  with  those 
of  the  ventral.  Strong,  fine  white  strands  of  connective  tissue,  blood, 
nerves,  and  lymph  vessels  bind  the  dorsal  surface  of  tne  abdominal  brain 
solidly  to  the  crura  diaphragmatica,  but  especially  strong  to  the  aortic. 
Nerves  originate  and  depart  from  the  dorsal  surface.  From  the  dorsal 
surface  nerves  depart  to  the  aorta  and  diaphragm  and  the  splanchnicus 
major,  bilaterally,  arrives  on  the  dorsal  surface. 

Ganglia. — There  are  usually  six  constant  ganglia  in  the  abdominal  brain, 
viz.:  (a)  Ganglia  diaphragmatic  (paired);  (b)  ganglia  splanchnica  (paired); 
(c)  ganglia  renalia  (paired).  They  are  solidly  and  compactly  united  into 
one  anatomic  and  physiologic  nerve  center — a  brain.  In  general  the  ganglia 
do  not  agree  in  form  or  dimension  bilaterally.  Practically  the  ganglia 
agree  in  position  bilaterally.  However,  the  left  semilunar  ganglion  is  nearer 
the  median  line  than  the  right,  and  the  left  mainly  lies  on  the  aorta,  while 
the  right  chiefly  rests  on  the  crus  of  the  diaphragm.  The  ganglia  may  rest 
in  an  even  transverse  plane,  or  lie  in  superimposed  layers  in  a  dorsoventral 
plane.  The  ganglia  constituting  the  abdominal  brain  are  as  irregular  and 
variable  as  the  plexus  in  which  they  are  located.  The  ganglia  consist  of 
large,  swollen  cords,  or  ganglionic  arches  or  circles  arranged  in  a  network. 
The  dimension,  form,  and  number  of  the  ganglia  may  vary  from  coalescence, 
isolation,  interpolation,  or  transportation  of  ganglia  along  vessels,  bones, 
and  muscles.  The  coalescence  of  the  ganglia  may  proceed  to  such  an 
extent  that  the  abdominal  brain  will  present  the  appearance  of  several 
nodes,  or  the  two  semilunar  ganglia  may  coalesce  and  lie  between  the  celiac 
and  superior  mesenteric  arteries. 

The  ganglia  may  coalesce  proximally  and  distally  in  the  form  of  a 
ganglionic  ring  surrounding  the  origin  of  the  celiac  and  mesenteric  arteries. 
The  ganglia  of  the  abdominal  brain  may  be  flat  or  elevated,  single  or  mul- 
tiple, united  by  gangliated  commissures  or  flattened  nerve  strands.  The 
nervus  splanchnicus  major,  the  essential  segment,  terminates  bilaterally  in 
the  abdominal  brain  in  a  large  semilunar  or  quadrilateral-shaped  nodule — 
ganglion  splanchnicum  (paired).  The  splanchnic  ganglia  may  assume  the 
shape  of  the  letter  C.  I  have  seen  two  splanchnic  ganglia  on  each  side  of 
almost  equal  dimensions  formed  by  the  splanchnic  major  and  minor  nerves. 

1.  The  left  semilunar  ganglion  has  a  more  definite  border,  is  nearer  to 
the  median  line,  greater  in  dorsoventral  diameter,  more  compact,  yet  smaller 
and  less  fenestrated  than  the  right.  It  lies  transversely  on  the  side  of  the 
aorta  between  the  renal  and  diaphragmatic  arteries.  Its  average  diameters 
are:  proximodistal,  V2  inch;  transverse,  1  inch;  dorsoventral,  \  inch.  Its 
thickest  border  is  the  left,  its  thinnest' is  the  right.  Its  ventral  surface  is 
uneven,  convex;  the  dorsal,  concave.  It  is  flask  or  quadrilateral  in  form. 
The  right  proximal  angle  is  elongated  into  a  horn-like  process  to  join  its 
opposite  fellow.  Afferent  nerves  arrive  and  efferent  nerves  depart  from  all 
surfaces  and  borders  except  part  of  the  left.  Proximally  it  is  connected  with 
the  diaphragmatic  ganglion— externally  with  the  splanchnic  nerve,  medially 
with  the  opposite  fellow  (right  half  of  brain). 


ABDOMINAL  BRAIN  (S.  P.). 
Fig.  35.  This  illustration  was  drawn  from  a  specimen  I secured  at .autopsy f  through  the 
courtesy  of  Dr.  W.  A.  Evans.     It  is  not  a  typical  abdominal  brain  on  account  of  the  peculiar 

trophied      The  ureters  present  a  network  of  nerves  surrounding  them.      Observe  the  large 
renal  ganglion  on  the   ventral  surface  of  the  renal  artery  at  U. 


120  THE  ABDOMINAL  AND  PELVIC  BRAIN 

2.  The  right  semilunar  ganglion  is  more  flattened,  greater  in  surface 
area,  more  extensively  fenestrated,  and  less  in  dorsoventral  diameter  than 
the  left.  It  lies  between  the  vena  cava  (ventral)  and  right  crus  of  the 
draphragm  (dorsal),  and  between  the  renal  and  diaphragmatic  arteries. 
Afferent  nerves  arrive  and  efferent  nerves  depart  from  its  surfaces  and 
borders.  The  left,  proximal,  angle  is  prolonged  into  a  horn-like  process  to 
join  its  opposite  fellow.  Proximally  it  is  connected  with  the  diaphragmatic 
ganglion ;  distally  with  the  renal  ganglion ;  externally  with  the  splanchnic 
nerve;  and  medially  with  the  opposite  fellow  (left  half  of  the  brain). 

Ganglion  of  the  Phrenic  Artery  {Ganglion  Arterial  Phrenicce). — In  this 
brief  note  I  wish  to  present  a  sympathetic  ganglion  (bilateral)  which  I  have 
not  found  described  in  literature. 

This  ganglion  consists  of  a  constant  pyramidal,  or  cone-shaped  projec- 
tion on  the  proximal  border  of  the  abdominal  brain  in  the  course  of  the 
phrenic  artery. 

In  Fig.  1  on  the  right  side  it  is  located  by  a  hook  at  the  figure  2  in  the 
abdominal  brain.  On  the  left  side  it  is  located  between  the  splenic  and 
phrenic  artery. 

The  phrenic  ganglion  projects  bulb-like  from  the  proximal  border  of  the 
cerebrum  abdominale  similar  to  that  of  the  olfactory  nerve  from  the  cranial 
cerebrum.  It  is  a  part  and  parcel  of  it.  By  a  general  observation  in  dis- 
secting the  sympathetic  nerve  (nervus  vasomotorius)  it  will  be  evident  that 
sympathetic  ganglia  are  located  at  the  origin  of  the  vessels  from  the  aorta, 
as  at  the  foot  of  the  celiac  axis  (ganglion  semilunare)  at  the  origin  of  the 
renal  artery  (ganglion  renale)  at  the  origin  of  the  arteria  mesenterica  inferior 
(ganglion  mesentericum  inferius)  at  the  origin  of  the  two  common  iliacs 
from  the  aorta  (the  interiliac  nerve  disc),  and  so  forth.  Hence  it  is  in 
accordance  with  this  rule  that  the  ganglion  arterias  phrenicae  is  found  in  the 
course  of  the  phrenic  artery  (bilateral).  If  the  phrenic  artery  has  an 
anomalous  origin  and  course  the  phrenic  ganglion  tends  to  follow  its  origin 
and  course,  and  it  was  this  anatomic  relation  that  called  my  attention  to 
this  heretofore  undescribed  constant  ganglion.  I  do  not  refer  to  the 
diaphragmatic  ganglion  (ganglion  diaphragmaticum)  located  on  the  dia- 
phragm on  the  right  side  (only)  about  two  inches  from  the  abdominal  brain. 
The  abdominal  brain  consists  practically  of  three  ganglia  (bilateral).  They 
are:  1.  Ganglion  semilunare  (bilateral),  located  on  the  middle  part  of  the 
lateral  border  of  the  abdominal  brain  at  the  termination  of  the  major  splanch- 
nic nerve  (Sp.  in  figures).  This  ganglion  is  related  to  the  origin  of  the 
celiac  artery.  2.  Ganglion  renale  (bilateral),  located  at  the  distal  lateral 
border  of  the  abdominal  brain,  and  belongs  to  the  origin  of  the  arteria 
renalis.  3.  Ganglion  arteria;  phrenicae  (bilateral),  located  at  the  proximal 
border  of  the  abdominal  brain  in  the  course  of  the  phrenic  artery. 

In  certain  subjects  the  ganglion  of  the  phrenic  artery  is  located  exactly 
at  the  origin  of  the  phrenic  artery  from  the  aorta.  However,  the  origin  of 
the  phrenic  artery  varies  considerably,  and  this  alters  to  some  extent  the 
relations  of  the  phrenic  ganglion  from  physical  facts. 


THE  ABDOMINAL  BRAIN 


121 


The  phrenic  ganglia  are  constant  structures,  constantly  located  in  relation 
to  the  course  of  the  phrenic  arteries  so  f;ir  as  I  can  determine  by  dissection. 
The  importance  of  the  abdominal  brain,  with  its  ganglia,  will  sooner  or 
later  be  realized  by  the  general  profession. 

The  diaphragmatic  ganglia  are  practically  bilaterally  symmetrical  in 
location,  form,  and  dimension.  They  project  as  pyramids  or  cones  from  the 
proximal  border  of  the  semilunar  ganglia,  at  the  origin  of  the  diaphragmatic 
arteries,  giving  origin  in  the  diaphragmatic  nerve.     They  project  from  the 


ABDOMINAL  BRAIN— CEREBRUM  ABDOMINALE. 

Fig.  36.  This  illustration  was  drawn  from  a  carefully  dissected  abdominal  brain.  1 
dissected  the  tissue  under  alcohol.  The  relations  and  proportions  are  those  of  life,  being 
drawn  by  accurate  measurements.  1  and  2,  abdominal  brain.  Observe  the  nerves  which 
the  adrenals  receive:  Sp,  splanchnic  major ;  DG,  ganglion  diaphragmaticum ;  GR,  renal 
ganglia;  Ad,  adrenals  ;  LS,  lesser  splanchnics ;  RA,  arteria  renalis ;  H,  hepatic ;  G,  gastric; 
and  Sp,  splenic  artery.  The  hook  fixes  the  ganglion  of  the  phrenic  artery  which  I  term 
ganglion  arteris  phrenicae. 

abdominal  brain  as  the  olfactory  projects  from  the  cranial  brain — being  a 
part  of  it.  The  diaphragmatic  nerve  possesses  a  small  ganglion  some  2lA 
inches  from  its  origin,  and  it  anastomoses  with  the  right  phrenic. 

5  and  6.  The  primary  renal  ganglia  are  practically  bilaterally  symmet- 
rical in  form,  location,  and  dimension.  Their  location  is  generally  at  the 
origin  of  the  renal  arteries. 

I.  The  ganglia  of  uncertain  dimension,  location,  and  form  associated 
with  the  abdominal  brain  are:  (a)  The  nervus  splanchnicus  minor  terminates 


122  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

bilaterally  more  distahvard  generally  on  the  renal  arteries;  (b)  the  ganglion 
suprarenale  supermini,  which  I  have  occasionally  found  chiefly  on  the  right 
suprarenal  nerves.  The  color  of  the  abdominal  brain  is  grayish-red ;  the 
consistence  is  moderately  dense,  due  to  the  presence  of  abundant  connective 
tissue;  the  composition  consists  of  an  aggregation  of  nerve  ganglia,  ensconced 
in  dense  connective  tissue,  varying  in  dimension,  number,  and  form.  Each 
ganglion  is  composed  of  oval-shaped  nerve  cells  of  various  form  and  dimen- 
sion. 

Relations. — The  relations  of  the  abdominal  brain  well  encased  in  fibrous 
and  connective  tissue  consist  in  intimate  connection  with  the  abdominal  aorta 
at  the  origin  of  the  celiac  axis,  superior  mesenteric  and  renal  arteries.  It 
has  also  intimate  but  less  solid  connections  with  the  vena  cava  and  renal 
veins.  It  is  a  vascular  brain  of  the  abdomen.  The  abdominal  brain  lies  in 
the  square  formed  by  the  proximal  renal  poles  with  adrenals  and  the  renal 
arteries.  It  is  in  relation  to  the  dorsal  surface  of  the  body  of  the  pancreas, 
peritoneum,  and  stomach.  The  abdominal  brain  in  general  occupies  the 
space  including  the  origin  of  the  major  visceral  arteries,  viz. :  (a)  arteria 
cceliaca;  (b)  arteria  mesenterica  superior;  (c)  arteria  renalis — three  mighty 
visceral  arteries  originating  from  the  aorta  within  the  space  of  an  inch  and 
a  half.  Hence  practically  the  term  abdominal  brain  should  include  the 
aggregated  or  coalesced  ganglia  located  at  the  origin  of  the  major  visceral 
vessels.  With  development  of  viscera  and  elongation  of  visceral  arteries, 
the  ganglia  become  isolated  from  the  original  abdominal  brain  and  trans- 
ported along  the  vessels  toward  the  viscera. 

The  two  best  examples  are  the  renal  and  aortic  arteries  with  their 
numerous  transported  large  ganglia — ganglia  renalia  and  ganglia  aortica. 
Development  has  sometimes  separated  the  cord  and  ganglion  of  the  nervus 
splanchnicus  minor  from  the  abdominal  brain  by  placing  it  more  distalward 
and  lateralward  toward  the  region  of  the  origin  of  the  arteria  renalis,  thus 
altering  the  form  and  contour  of  the  abdominal  brain.  The  nerve  plexuses 
and  ganglia  of  the  abdominal  brain,  firmly  bound  in  sheaths  by  strong  white 
connective  and  elastic  tissue,  encase  the  visceral  vessels  and  accompany 
them  to  the  viscera.  The  abdominal  brain  is  solidly  and  compactly  anas- 
tomosed, connected  by  nerves  of  various  caliber  with  all  the  abdominal 
viscera,  viz.,  tractus  intestinalis,  urinarius,  genitalis,  vascularis,  lymphaticus. 
It  is  evident  from  its  location  at  the  origin  of  the  celiac  axis  and  superior 
mesenteric  arteries  that  the  abdominal  brain  in  its  origin  was  a  primitive  brain 
for  the  tractus  vascularis.  With  development  of  viscera  and  elongation  of 
visceral  arteries,  dislocation,  multiplication,  distribution,  coalescence  or 
transportation  of  ganglia,  other  viscera  have  acquired  local  ganglionic  rulers, 
e.g.,  the  pelvic  brain — ganglion  cervicale.  However,  present  conditions 
allow  the  origin  of  the  abdominal  brain  to  remain  at  the  exit  of  the  major 
visceral  vessel.     It  should  be  denominated  a  vascular  brain. 

From  the  abdominal  brain  radiate  plexuses  of  various  caliber,  chiefly  in 
vessels,  to  all  the  abdominal  viscera,  viz.,  tractus  intestinalis,  genitalis, 
urinarius,  vascularis,  and  lymphaticus.       The  abdominal  brain  emits  more 


THE  ABDOMINAL   BRAIN  123 

nerves  than  it  receives,  and  hence  is  a  creating,  producing  center,  a  source 
for  new  and  increased  nerves.  Nerve  reception  occurs  chielly  at  the 
proximal  (plexus  aorticus  thoracalis,  vagi)  and  lateral  borders  (splanchnics, 
major,  medius,  minor).  Nerve  emission  occurs  mainly  at  the  distal  (plexus 
aorticus  abdominalis)  and  lateral  borders  (plexus  renalis,  adrenalis).  From 
the  dorsal  and  ventral  surface,  from  the  bilateral  proximal  and  distal  borders 
of  the  abdominal  brain,  nerves  arrive  and  depart.  Bilaterally  radiate  the 
renal  and  adrenal  nerves,  and  arrive  the  splanchnicus;  proximally  radiate  a 
few  to  the  aorta,  and  arrives  the  plexus  aorticus  thoracalis  and  vagi;  dorsally 
many  nerves  pass  to  the  aorta  and  diaphragm,  and  arrive  the  branches  from 
the  splanchnics;  ventrally  a  number  of  nerves  radiate  to  the  adrenals  and 
pancreas;  distally  are  emitted  nerve  plexuses  of  vast  importance  on  visceral 
arteries  of  corresponding  names,  viz.  : 

I.  Tractus  intestinalis:  (1)  Plexus  cceliacus,  emitting  (a)  plexus 
gastriticus  accompanying  the  arteria  gastrica;  (b)  plexus  hepaticus  accom- 
panying the  arteria  hepatica;  (c)  plexus  lienalis  accompanying  the  arteria 
lienalis.  (2)  Plexus  mesentericus  superior  accompanying  the  arteria  mes- 
enterica  superior  (to  the  enteron — except  the  duodenum,  and  colon,  except 
the  cacum,  right  colon  and  right  half  of  transverse  colon).  (3)  Plexus 
mesentericus  inferior  accompanying  the  arteria  mesenterica  inferior  (to  the 
left  half  of  the  transverse  colon,  left  colon,  sigmoid  flexure,  and  rectum). 

II.  Tractus  urinarius:  (1)  Plexus  adrenalis  accompanying  the  arteria 
adrenalis.  (2)  Plexus  renalis  accompanying  the  arteria  renalis.  (3)  Plexus 
ureteris  accompanying:  (a)  rami  arteria:  renales;  (b)  arteria  ovarica;  (c) 
arteria  ureteris  media  (from  common  iliac) ;  (d)  arteria  uterina.  (4)  Plexus 
hsemorrhoidalis  accompanying  the  arteria  hgemorrhoidalia.  (5)  Plexus 
hypogastrics  accompanying  the  arteria  hypogastrica.  (6)  Pelvic  brain 
(ganglion  cervicale)  emits  nerves  which  pass  directly  to  the  ureter  without 
accompanying  blood-vessels  as  well  as  the  plexus  vesicalis.  (7)  Plexus 
vesicalis  accompanying  the  arteria  vesicalis  superior,  media,  and  inferior 
(hemorrhoidal).  (8)  Plexus  urethralis  (a  continuation  of  the  plexus  vesi- 
calis) accompanying  arteria  pudenda. 

III.  Tractus  genitalis:  (1)  Plexus  aorticus  accompanying  the  arteria 
aortica  abdominis.  (2)  Plexus  hypogastricus  (a  continuation  of  the  plexus 
aorticus)  accompanying  the  arteria  iliaca  communis  and  arteria  hypogastrica. 
(3)  Plexus  ovaricus  accompanying  the  arteria  ovarica.  (4)  Plexus  arteriae 
uterinse  accompanying  the  arteria  uterina.  (5)  Cerebrum  pelvicum  (pelvic 
brain),  which  emits  the  plexus  uterinus  without  accompanying  vessels  as  well 
as  the  plexus  vaginalis.  The  sympathetic  nerve  cords  and  ganglia  accom- 
panying vessels  (blood,  particularly  arteries  and  lymph)  arranged  as  a  network 
in  a  connective  tissue  sheath  which  encases  the  vessel. 

(b)  physiology  of  the  abdominal  brain. 

In  mammals  there  exist  two  brains  of  almost  equal  importance  to  the 
individual  and  race.  One  is  the  cranial  brain,  the  instrument  of  volitions 
of  mental  progress  and  physical  protection.       The  other  is  the  abdominal 


124  THE  ABDOMINAL  AND  PELVIC  BRAIN 

brain,  the  instrument  of  vascular  and  visceral  function.  It  is  the  automatic, 
vegetative,  the  subconscious  brain  of  physical  existence.  In  the  cranial 
brain  resides  the  consciousness  of  right  and  wrong.  Here  is  the  seat  of  all 
progress,  mental  and  moral,  and  in  it  lies  the  instinct  to  protect  life  and  the 
fear  of  death.  However,  in  the  abdomen  there  exists  a  brain  of  wonderful 
power  maintaining  eternal,  restless  viligance  over  its  viscera.  It  presides 
over  organic  life.  It  dominates  the  rhythmical  function  of  viscera.  It  is  an 
automatic  nerve  center,  a  physiologic  and  an  anatomic  brain.  Being  located 
at  the  origin  of  the  celiac,  superior  mesenteric,  and  renal  arteries — the  major 
abdominal  visceral  arteries — it  is  a  primary  vascular  brain  of  the  abdomen 
and  a  secondary  brain  for  visceral  rhythm.  The  abdominal  brain  presides  as 
the  central  potentate,  over  the  physiology  of  the  abdominal  viscera.  The 
common  functions  of  these  viscera  are  rhythm,  secretion,  and  absorption, 
and  to  preside  over  this  triple  office  is  the  chief  duty  of  the  abdominal  brain. 
To  the  common  functions  of  the  abdominal  viscera  must  be  added  the  special 
functions  of  the  tractus  genitalis — ovulation,  menstruation,  gestation; 
however,  many  of  the  functions  of  the  visceral  tract  are  delegated  to  the 
subordinate  local  ruler — the  pelvic  brain.  The  abdominal  brain  is  a  receiver, 
a  reorganizer,  an  emitter  of  nerve  forces.  It  has  the  powers  of  a  brain.  It 
is  a  reflex  center  in  health  and  disease.  The  sympathetic  abdominal  nerve 
alone  possesses  the  power  of  rhythm.  Every  organ  possesses  rhythm.  In 
this  rhythm  of  involuntary  visceral  muscles  is  doubtless  included  the  factors 
of  initiation,  maintenance,  and  conclusion  of  visceral  absorption  and  secre- 
tion. The  rhythmic,  peristaltic  muscles  massage  the  glands,  inciting  their 
function  of  secretion  and  absorption. 

The  individual  functions  of  the  abdominal  brain  are  numerous  and 
important,  viz. :  (1)  It  is  the  source  of  new  nerves,  as  it  possesses  more 
efferent  than  afferent  nerves.  (2)  it  demedullates  nerves;  nerves,  enter 
sheathed  and  depart  unsheathed.  (3)  It  presides  over  the  rhythm,  peristalsis, 
of  visceral  muscles.  (4)  It  presides  over  the  absorption  and  secretion  of 
visceral  glands — e.g.,  the  glands  lining  tubular  viscera  and  those  denominated 
glandular  appendages.  (5)  The  abdominal  brain  is  a  giant  vasomotor  center, 
controlling  the  caliber  of  the  abdominal  vessels  (blood  and  lymph) ;  it  should 
be  termed  ncrvus  vasomotorius.  (6)  It  possesses  nutritive  powers  over  the 
nerves  passing  from  it  to  the  periphery.  (7)  It  is  the  major  abdominal 
reflex  center. 

The  abdominal  brain  is  not  a  mere  agent  of  the  brain  and  cord;  it 
receives  and  generates  nerve  forces  itself;  it  presides  over  nutrition.  It  is 
the  center  of  life  itself.  In  it  are  repeated  all  the  physiologic  and  pathologic 
manifestations  of  visceral  function  (rhythm,  absorption,  secretion,  and 
nutrition).  The  abdominal  brain  can  live  without  the  cranial  brain,  which 
is  demonstrated  by  living  children  being  born  without  cerebrospinal  axis. 
On  the  contrary  the  cranial  brain  can  not  live  without  the  abdominal  brain. 
The  central  idea  founded  in  the  abdominal  brain  should  entitle  it,  in  my 
opinion,  to  the  name  vascular  or  vasomotor  brain  of  the  abdomen  (cerebrum 
vasculare  abdominale).     It  initiates,  sustains,  and  concludes  visceral  rhythm 


THE  ABDOMINAL  BRAIN 


l-j- 


(the  peristalsis  of  involuntary,  visceral  muscles) — e.g.,  in  the  tractus 
vascularis,  intestinalis,  genitalis,  and  urinarius.  It  presides  over  the  absorp- 
tion and  secretion  of  the  viscera — e.  g.t  the  mucous  glands  of  the  tubular 
viscera  and  visceral  glandular  appendages.  It  is  evident  from  the  great 
volume  of  blood  occasionally  found  in  the  vastly  distended  abdominal  veins 
at  autopsy  that  a  subject  could  bleed  to  death  in  his  own  abdominal  vessels. 
The  abdominal  brain,  the  vascular  cerebrum,  is  responsible  for  this  condition, 


ABDOMINAL  BRAIN. 


Fig.  37.  This  illustration  drawn  from  a  cadaver,  illustrates  the  location,  relation,  and 
radiating  plexuses  jof  the  solar  plexus,  or  abdominal  brain  (71  and  72),  which  is  built 
around  the  major  visceral  arteries,  the  celiac  (73,  74,  75),  superior  mesenteric  (106),  and 
renal  (88)  arteries ;  hence  it  dominates  the  visceral  function  as  to  vascularity  (blood  and 
lymph),  peristalsis,  absorption,  and  secretion.  The  clinical  manifestations  of  theabdominat 
brain  are  coextensive  with  that  of  the  abdominal  viscera.  This  ganglion  of  the  firsl 
magnitude  presents  radiating  plexuses  to  all  the  abdominal  viscera,  presenting  an  exquisitely 
balanced  and  poised  nervous  mechanism,  controlling  vascularity  (blood  and  lymph), 
peristalsis,  absorption,  and  secretion.  76  and  185,  splanchnic  major;  110,  111,  ganglia 
ovarica.  The  body  from  which  this  dissection  was  drawn  possessed  wide,  flat  nerves,  as 
is  noted  by  the  majestic  ganglion — the  abdominal  brain  or  cerebrum  vasomotorius ;  69  is 
the  left  vagus. 


126  THE  ABDOMINAL  AND  PELVIC  BRAIN 

having  forgotten,  from  paralysis,  to  control  the  lumen  of  the  vessels.  From 
the  anatomic  vascular  connection  it  is  impossible  to  extirpate  the  abdominal 
brain  from  living  animals,  hence  the  reports  of  experimentation  accompanied 
with  its  extirpation  are  unreliable.  The  abdominal  brain  is  the  nervous 
executive  of  the  abdominal  vessels  and  viscera,  the  duties  of  which  are  to  see 
that  the  functions  of  the  viscera  (rhythm,  secretion,  and  absorption)  are 
faithfully  executed.  The  abdominal  brain  assumes  practically  an  indepen- 
dent existence;  however,  the  cerebrospinal  axis  asserts  a  controlling 
influence  over  it.  For  example,  in  children  whose  cerebrospinal  axis  is  not 
completely  developed,  and  at  death  of  adults,  when  the  cerebrospinal  axis 
has  lost  its  complete  control,  the  intestines  will  mutiny,  assuming  a  wild, 
disordered,  violent  peristalsis,  resulting  in  intestinal  invagination. 

The  utility  of  the  abdominal  brain  in  practice  is  important — for  example, 
in  postpartum  hemorrhage  the  older  practitioners  taught  that  by  compression 
of  the  aorta  the  hemorrhage  was  checked.  This,  of  course,  is  an  error,  as 
the  technique,  if  it  were  possible  to  execute,  would  not  materially  affect  the 
bleeding,  as  ovarian  blood-supply  would  continue.  The  physiologic  expla- 
nation of  checking  postpartum  hemorrhage  by  pressure  over  the  abdominal 
aorta  is  that  the  manipulation  stimulates  the  plexus  aorticus  and  plexus 
hypogastrics,  which  is  transmitted  to  the  pelvic  brain,  where  it  is  reor- 
ganized and  transmitted  over  the  plexus  uterinus  to  the  myometrium,  the 
elastic  and  muscular  bundles  of  which  being  excited,  contract  like  living 
ligatures,  checking  the  postpartum  hemorrhage  by  diminishing  the  lumen  of 
the  vessels.  The  irritation,  pressure,  or  trauma  of  the  head  of  the  child  on 
the  expanding  cervix  uteri  during  the  last  month  of  gestation  precipitates 
labor  by  its  effect  on  the  pelvic  brain  (and  consequently  on  the  abdominal 
brain),  by  inducing  vigorous,  persistent  uterine  contractions.  In  feeble 
labor  pains,  during  uterine  inertia,  vigorous  uterine  contractions  may  be 
excited  by  the  finger  per  rectum  or  per  vaginam,  irritating  or  massaging  the 
pelvic  brain.  The  pelvic  brain  is  palpated  with  facility,  as  it  is  located  on 
the  lateral  vaginal  fornix.  Again,  the  pelvic  brain  is  subordinate  to  the 
abdominal  brain ;  however,  the  pelvic  brain  must  be  intact  to  allow  physio- 
logic orders  to  pass  from  the  abdominal  brain  through  the  pelvic  brain  to  the 
uterus.  For  example,  during  labor  sudden  cessation  of  uterine  peristalsis 
may  occur — uterine  inertia.  The  probable  explanation  is  that  as  the  head 
passes  through  the  pelvis  it  traumatizes  the  pelvic  brain,  producing  temporary 
paresis  from  pressure,  and  partially  checks  the  uterine  rhythm.  With  the 
progress  of  labor  the  pelvic  brain  recovers  and  its  dynamics  resume. 

The  temporary  paresis  of  the  pelvic  brain  does  not  produce  complete 
paralysis,  because  a  few  of  the  nerves  of  the  plexus  hypogastricus  (directly 
from  the  abdominal  brain)  pass  to  the  uterus  without  first  entering  the  pelvic 
brain.  The  abdominal  brain  rules  the  physiology  of  the  abdominal  visceral 
tracts.  The  methods  to  utilize  the  physiology  of  the  abdominal  brain  in 
practice  are  varied.  For  example,  the  mammary  gland  is  connected  to  the 
abdominal  brain  by  at  least  three  distinct  routes,  viz. :  (a)  via  the  nerve 
plexuses  accompanying  the  arteria  mammaria  and  arteria  subclavia,  whence 


THE  ABDOMINAL   BRAIN 


127 


the  route  is  direct  to  the  abdominal  brain;  (b)  via  the  nerve  plexuses 
accompanying  the  arteriae  intercostales  to  the  aorta  and  its  plexus,  whence 
the  route  is  direct  to  the  abdominal  brain;  (c)  via  the  nerve  plexuses  accom- 
panying the  arteria  epigastrica  superior  and  inferior  to  the  common  iliac, 
whence  the  route  (plexus)  continues  on  the  artery  of  the  round  ligament  to 
the  plexus  uterina,  whence  the  route  is  direct  to  the  pelvic  brain  or  abdominal 
brain.  Therefore,  by  stimulating  or  irritating  the  nipple  with  light  friction 
or  massaging  the  mammary  gland,  the  abdominal  brain  is  reached  by  the 
above  three  routes,  and  consequently  the  uterus  is  induced  to  contract  more 
frequently,  and  if  the  experiments  be  not  repeated  too  rapidly,  the  uterine 
contraction  will  be  more  vigorous.  Again,  the  uterus  may  be  incited  to  more 
frequent  and  vigorous  contractions  by  administering  a  tablespoonful  of  hot 


GANGLION  CELLS  IN  THE  ABDOMINAL  BRAIN. 

Fig.  38.  Drawn  from  a  microscopic  section  of  the  abdominal  brain.  Observe  that 
the  cells  lie  in  connective  tissue  nests,  i.  e.,  the  ganglion  cells  are  ensconced  in  separate 
chambers  of  connective  tissue.  The  prolongations  of  the  cells,  i.  <?.,  the  conducting  cords, 
pass  hither  and  yon,  forming  a  network. 


fluid,  which  first  emits  the  stimulation  over  the  plexus  gastricus  to  the 
abdominal  brain,  where  it  is  reorganized  and  sent  directly  to  the  plexus 
uterinus,  which  incites  the  uterus  to  increased  peristalsis.  The  reverse 
physiology  of  the  influence  of  visceral  tumors  or  pregnant  genitals  stimu- 
lating the  mammary  gland  (over  the  above  three  routes)  is  evident.  The 
tumor  or  fetus  in  the  genitals  rapidly  induces  the  mammary  gland  to  mani- 
fest objective  disturbances  of  dimension,  circulation,  color,  palpation,  as 
well  as  sensory  disturbances. 

Practically  the  uterine  nerves  originate  in  the  abdominal  brain  and 
possess  a  relative  independent  existence.  Children  are  born,  expelled,  from 
the  uterus  after  the  death  of  the  mother.  Hyrtl,  the  celebrated  Viennese 
anatomist,  reports  that  during  a  war  with  Spain  some  bandits  hanged  a 
pregnant  woman.  After  she  had  hung  on  the  gallows  for  four  hours,  and  con- 
sequently was  long  dead,  she  gave  birth  to  a  living  child.  I  have  observed  the 
giant  uterus  of  slaughtered  pregnant  cows  executing  with  wondrous  precision 


128  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

its  rhythm  hours  subsequent  to  death  and  evacuation  of  uterine  contents.  If 
one  will  extirpate  an  oviduct  from  a  human  and  place  it  in  warm  normal  salt 
solution,  oviductal  rhythm  may  be  maintained  by  physical  stimulus — e.g.% 
tapping  with  the  scalpel — for  some  three-quarters  of  an  hour.  If  one  will 
chloroform  a  dog  to  death  and  incise  the  abdominal  wall,  exposing  the  intes- 
tines, in  a  room  of  70°,  the  intestines  will  perform  their  rhythm,  on  being 
tapped  with  the  scalpel,  for  an  hour  and  a  half.  The  large  urinary  vesical 
apparatus  of  steers  will  perform  rhythmical  movements  for  half  a  dozen 
hours  after  death  in  summer  temperature. 

The  anatomic  location  and  the  physiologic  function  of  the  abdominal 
brain  dignify  it  into  a  basic  factor  in  diagnosis  from  pain.  For  example, 
practically  all  acute  inflammatory  pain  (localized  peritonitis,  visceral  perfor- 
ation) or  violent  visceral  irritation  (calculus,  volvulus,  invagination,  acute 
strangulation,  obstruction)  is  first  experienced  in  the  epigastric  region — i.e., 
reorganization  occurs  in  the  abdominal  brain.  This  means  that  all  visceral 
pain,  irritation,  is  first  transmitted  to  the  abdominal  brain,  where  it  is 
reorganized  and  emitted  to  the  abdominal  viscera,  diffusing  the  wild, 
disordered,  violent  peristalsis  (colic)  universally  in  the  abdomen,  which 
prevents  the  localizing  of  the  pain  by  the  diagnostician.  With  the  progress 
of  the  disease  the  abdominal  brain  and  associated  nerve  apparatus  become 
accustomed  to  the  new  experience  and  the  pain  becomes  intensified,  local- 
ized on  definite  nerve  plexuses,  whence  the  pain,  tenderness,  can  be  diagnosed 
by  distinct  circumscribed  localization.  The  best  example  of  this  view  is 
appendicitis. 

The  abdominal  brain  is  the  seat  of  shock.  A  blow  over  the  epigastrium, 
violent  trauma  to  the  abdominal  brain,  may  cause  immediate  shock, 
collapse,  or  death.  I  performed  an  autopsy  on  a  subject  where  invagination 
of  the  uterus  had  killed  the  patient  in  two  and  a  half  hours.  Death  was  due 
to  shock  in  the  abdominal  brain,  transmitted  to  it  over  the  hypogastric  plexus 
from  the  traumatized  (invaginated)  uterus. 

CONCLUSIONS  AS  REGARDS  THE  ABDOMINAL  BRAIX. 

The  abdominal  brain  is  a  nervous  center — i.e.,  it  receives,  reorganizes, 
and  emits  nerve  forces. 

The  abdominal  brain  is  the  nervous  executive  for  the  common  functions 
of  the  abdominal  viscera,  as  rhythm,  absorption,  and  secretion. 

The  abdominal  brain  was  originally  in  function  and  location  a  vascular 
brain — cerebrum  vasculare.  Though  complicated  functions  have  been 
added,  yet  it  is  still  a  primary  vasomotor  center  controlling  the  caliber  of  the 
blood-vessels  and  consequently  the  volume  of  blood  to  viscera,  which 
determines  visceral  function. 

The  abdominal  brain  is  a  reflex  center  in  health  and  disease. 

It  is  the  major  assembling  center  of  the  abdominal  sympathetic. 

The  abdominal  brain  is  the  seat  of  shock.  A  blow  or  trauma  on  it  may 
cause  shock,  collapse,  or  death. 

It  is  the  automatic,  vegetative,  the  subconscious  brain  of  physical 
existence.     It  is  the  center  of  life  itself. 


THE  ABDOMINAL   BRAIN  129 

In  the  abdominal  brain  are  repeated  all  the  physiologic  and  pathologic- 
manifestations  of  visceral  function — rhythm,  absorption,  secretion,  men- 
struation, gestation,  ovulation. 

The  abdominal  brain  can  live  without  the  cranial  brain  (and  spinal 
cord),  for  children  have  been  born  alive  with  no  cerebrospinal  axis.  Chil- 
dren have  been  born  alive  hours  after  the  mother  was  dead. 

The  abdominal  brain  may  be  the  agent  of  valuable  therapeutics — e.g.y 
in  postpartum  hemorrhage  massage  of  the  aortic  plexus  will  stimulate  the 
abdominal  brain  to  control  the  blood-vessels  of  the  uterus.  Massage  of  the 
aortic  plexus  will  stimulate  the  abdominal  brain  to  send  blood  to  the  viscera, 
enhancing  rhythm,  secretion,  and  absorption,  improving  constipation  and 
increasing  visceral  drainage. 

The  abdominal  brain  is  the  primary  agent  of  rhythmic  visceral  motion. 
A  wide  office  of  the  physician  is  to  maintain  regular  visceral  rhythm  by 
means  of  rational  therapeutics,  as  regular  habits  and  exercise,  wholesome 
coarse  food,  ample  fluids,  and  proper  rest. 


CHAPTER  XIII. 

THE  PELVIC  BRAIN  (CEREBRUM  PELVICUM). 

We  do  automatically  what  we  do  well. 

"La  Duma  est  morte!  vive  la  Duma!" — ("The  Russian  parliament  is  dead! 
Long  live  the  Russian  parliament!"  ) — Remark  of  Sir  Henry  Campbell-Ban- 
' nerman.  Prime  Minister  of  England  during  the  Inter-Parliamentary  Congress 
Session  at  London.  July 24, 1906. 

(a)  anatomy,    (b)  PHYSIOLOGY,    (c)  PATHOLOGY. 

Prologue. — With  the  term  cervical  ganglion  the  names  of  Johann  Gotlieb 
Walther  (1734-1818),  Robert  Lee  (1793-1877)  and  Ferdinand  Frankenhauser 
(died  in  1894)  will  be  forever  connected.  Thomas  Snow  Beck  (1814-1847,) 
will  be  remembered,  in  the  brilliant  polemics  only,  from  1840  to  1*46,  with 
Robert  Lee.  Walter's  book  appeared  in  1783.  Lee's  in  1841  and  Franken- 
hauser's  in  1867 — all  with  illustrations  of  the  cervical  ganglion.  The  first 
two  books  are  pioneer  works  executed  in  the  premicroscopical  days;  the 
last  work,  that  of  Frankenhauser,  is  a  work  of  scientific  merit,  and  will  stand 
the  test  of  time.  I  have  designated  the  plexiform  ganglionic  mass,  located  on 
the  lateral  border  of  the  cervix  and  vagina,  as  the  pelvic  brain.  The  gang- 
lionated  mass  located  at  the  cervico-vaginal  function  has  experienced  a 
variety  of  terms  during  the  past  two  centuries. 

Synonyms. — The  pelvic  sympathetic  plexus  (plexus  sympathicus); 
Cervio-cuterine  ganglion  (ganglion  cervicis  uterinum — Walther,  1783). 
Hypogastric  plexus  (plexus  hypogastricus — Walter,  1783).  The  lateral 
hypogastric  plexus  (plexus  hypogastricus  lateralis — Friedrich  Tiedemann, 
1822)  (1781-1861).  The  ganglionated  plexus  (plexus  gangliosus — Tiedemann, 
1822).  The  inferior  uterine  plexus  (plexus  uterinus  inferior — Tiedemann, 
1822).  The  hypogastric  ganglion  (ganglion  hypogastrium — Lee,  1841).  The 
uterocervical  ganglion  (ganglion  uterium  cervicale — Lee,  1841).  The  vesico- 
rectal plexus  (plexus  vesicis  rectalis — J.  M.  Bourgery,  1840)  (1797-1845),  and 
Claude  Bernard  (1813-1878).  The  ganglion  of  the  cervix  (ganglion  cervicis — 
Lee,  1841).  The  pelvic  plexus  (plexus  pelvicus — Thomas  Snow  Beck,  1845) 
(1814-1847).  The  cervical  ganglion  (ganglion  cervicale — Frankenhauser, 
1867).  The  fundamental  nerve  plexuses  of  the  uterus  (plexus  nervosus  fun- 
damental uteri — G.  Rein,  1892),  Pelvic  brain  (cerebrum  pelvicum — Byron 
Robinson,  1894).  The  lateral  cervical  plexus  (plexus  lateralis  cervicis).  The 
utero-vaginal  plexus  (plexus  uterinus  vaginalis). 

Practically  three  views  have  been  entertained  in  regard  to  Lie  nature 
and  character  of  the  pelvic  brain;  viz. : 

(a)  It  is  a  more  or  less  solid,  composite,  ganglionic  mass — Walter  (1783), 
Lee  (1841),  Frankenhauser  (1867),  Freund  (1885),  Byron  Robinson  (1894), 
Knupffer  (1892). 

(b)  It  is  a  ganglionated  plexus  or  group  of  connected  ganglia — Tiedemann 

130 


ANATOMY  131 

(1822),  Moreau  (1789-1862),  Jastreboff  (1881),  Rein  (1902),  Sabura  Hashimoto 
(1892),  Pessimski  (l<s(-»->,  Jung  (1905). 

(c)  Jobert  (de  Lomalle)  (1799-1867),  1841,  and  Thomas  Snow  Beck,  1845 
(1814-1877),  are  the  only  authors  known  to  me  who  have  viewed  the  pelvic 
brain  as  a  nongangliated  nerve  plexus. 

(A)  Anatomy  and  Topography  of  the  Pelvic  Brain. 

Position. — I.  Holotopy  (relation  to  general  body).  The  pelvic  brain  is 
located  in  the  distal  end  of  the  abdominal  cavity.  It  is  a  bilaterally  located 
organ  (paired)  residing  in  the  lesser  pelvic  between  the  cervic  uteri  and 
pelvic  wall.  It  is  situated  extraperitoneally  at  the  base  of  the  ligamentum 
latum,  proximal  to  the  pelvic  floor,  ensconced  in  the  pelvic  subserous 
connective  tissue.  The  pelvic  brain  is  completely  accessible  to  digital 
palpation. 

II.  Skeletopy  (relation  to  the  osseous  system).  The  pelvic  brain  lies 
in  the  lesser  bony  pelvis,  located  bilaterally  closely  adjacent  to  the  ischial 
spine  in  the  planum  interspinosum.  It  lies  on  a  level  with  the  II  sacral 
vertebra  and  the  proximal  border  of  the  symphysis  pubis.  By  distention 
and  contraction  of  rectum,  bladder,  vagina  and  uterus  the  skeletopic  relation 
of  the  pelvic  brain  becomes  altered.  The  pelvic  brain  lies  practically  midway 
between  the  inlet  and  outlet  of  the  minor  osseous  pelvis.  The  skeletopic 
relation  of  the  pelvic  brain  has  been  modified  by  erect  attitude. 

III.  Syntopy  (relation  to  adjacent  organs).  The  pelvic  brain  (paired) 
is  located  bilaterally  to  the  cervix  uteri  and  vaginal  fornix.  It  is  situated  in 
the  connective  tissue  of  the  parametrium,  on  a  level  with  the  middle  of  the 
cervix  uteri  and  about  one  inch  lateralward  from  the  cervix  uteri.  The 
pelvic  brain  is  located  in  the  base  of  the  ligamentum  latum  at  the  distal  end 
of  the  plexus  interiliacus  (hypogastrics).  Practically  the  pelvic  brain  is 
located  at  the  crossing  of  the  ureter  and  pelvic  floor  segment  of  the  vasa 
uterina.  It  lies  on  the  internal  border  of  the  ureter  midway  between  the 
dorsal  and  ventral  blades  of  the  ligamentum  latum  in  the  loose  connective 
tissue.  It  is  situated  at  the  junction  of  the  plexus  interiliacus,  hypogastrics, 
with  the  branches  of  the  II,  III,  and  IV  sacral  nerves  (spinal).  It  is  lodged 
practically  at  the  junction  of  the  cervix  uteri  with  the  vaginal  fornix.  A 
major  portion  of  it  may  lodge  in  the  groove  or  fossa,  between  the  rectum 
and  vagina.  It  is  surrounded  and  interwoven  with  dense,  subperitoneal, 
pelvic  connective  tissue,  presenting  difficulties  in  exposition  by  dissection 
because  of  its  simulation  to  adjacent  tissue.  The  pelvic  brain  has  profound 
and  extensive  connection  with  the  uterus,  vagina,  and  rectum,  ureter  and 
bladder.  In  the  majority  of  subjects  the  chief  segment  of  the  pelvic  brain 
lies  adjacent  to  the  lateral  vagina  fornix.  From  erect  attitude  the  pelvic 
brain  has  changed  its  position,  having  approached  more  adjacent  to  the  cer- 
vico-vaginal  junction  in  the  center  of  the  pelvis.  From  the  distalward  and 
ventralward  movements  of  the  genitals  (in  higher  forms  of  life  and  erect 
attitude)  the  plexus  interilicus  (hypogastricus)  has  been  dragged,  forced 
medianward,    isolating   it    from   the   arteria   iliaca    communis    and    arteria 


132 


THE  ABDGMLXAL  AND.  PELVIC  DRAIN 


PELVIC  BRAIN  OF  AX  INFANT 

Fig.  39.  A,  pelvic  brain;  B,  plexus  vesicalis  ;  V,  plexus  vaginalis;  I,  II,  III,  IV,  V, 
sacral  nerves  with  the  sacral  ganglia  (N),  plexus  (hypogastricus)  ;  P.  I.  Ur.,  ureter;  Ut., 
uterus;  B,  bladder;  v,  vagina;  R,  rectum;  O,  oviduct  5  L  V,  lumbar  nerve;  D:  interiliac 
nerve  disc. 

The  pelvic  brain  in  this  infant,  viewed  with  a  lens,  presents  the  afferent  nerves  arriving 
from  the  plexus  interiliacus  (P.  I.),  nervi  sacrales,  ganglia  sacralia,  mainly  as  single  nerve 
cords,  at  most  slightly  plexiform  at  the  distal  end  of  the  plexus  interiliacus.  With  a  magni- 
fying lens  the  efferent  nerves  of  this  pelvic  brain  (plexus  ,  rectalis,  vaginalis,  vesicalis, 
uterinus)  resemble  luxuriant  leashes  (cat  o'  nine  tails)  or  richly  ganglionated  plexuses. 
The  pelvic  brain  in  this  subject  has  the  following  efferent  leashes  :  (a)  the  plexus  rectalis 
presents  some  seven  emissions  of  large  nerves,  coursing  distalward  on  the  rectal  wall,  richly 
supplying  the  rectum.  It  has  the  most  limited  number  of  nerve  trunks  and  ganglia  of  any 
of  the  efferent  leashes  of  the  pelvic  brain ;  {b)  plexus  vaginalis  presents  some  eight  emissions 


ANATOMY  1 

hypogastrica,  and  the  sacral  nerve  branches  which  unite  with  the  distal  end 
of  the  plexus  interiliacus  (to  form  the  pelvic  brain)  have  become  elongated, 
hence  the  pelvic  brain  is  not  intimately  and  profoundly  associated  with  its 
original  great  blood-vessels,  resembling  the  profound  connection  of  the 
abdominal  brain  with  its  blood-vessels.  Yet  the  pelvic  brain  is  still  a  vas- 
cular brain  (cerebrum  vasculare)  associated  with  blood-vessels  or  a 
vasomotor  brain  (cerebrum  vasomotorius),  for,  by  controlling  the  blood 
supply  of  the  uterus,  it  controls  its  rhythm  and  secretion.  The  ganglia  of 
the  pelvic  brain  are  interspersed  with  fenestra,  interwoven  with  rich  con- 
nective tissue,  intertwined  with  many  arteries  and  numerous  veins.  The 
pelvic  brain  is  a  ganglionated  plexiform  apparatus  intimately  associated  with 
the  uterus.  Distention  and  contraction  of  pelvic  organs,  with  consequent 
change  of  visceral  location,  alters  to  a  relative  degree  the  syntopic  relations 
of  the  pelvic  brain. 

IV.  Idiotopy  (relation  of  component  segments).  The  pelvic  brain 
is  practically  a  triangle,  frequently  a  quadrangle  in  form  with  its  apex 
proximalward.  Its  base  is  essentially  on  a  level  with  the  IV  sacral  nerve. 
At  its  proximal  end  and  lateral  border  it  receives  (afferent)  nerves  in  the 
form  of  cords  slightly  plexiform.  At  its  distal  end  (base)  and  medial  border 
it  emits  (efferent)  nerves  in  the  form  of  leashes  and  complicated  plexuses. 
Practically  its  medial  border  is  divided  by  two  septa;  viz.,  (a)  the  septum 
rectale  and  (b)  septum  vaginale,  which  divide  the  ventral  and  dorsal  nerve 
branches  and  leashes  supplying  the  dorsal  and  ventral  surfaces  of  the 
respective  organs.  There  is  no  segmental  or  other  practical  division  of  the 
component  segment  of  the  pelvic  brain ;  it  is  a  single,  composite,  gang- 
lionated mass — a  unit.  As  to  function,  the  ganglia  of  the  pelvic  brain  are 
not  differentiated  in  function  similar  to  those  of  the  ganglia  of  the  cranial 
brain. 

Dimension. — The  average  dimensions  of  the  adult  pelvic  brain  in  the 
resting  uterus  are:  Length  (proximo-distal),  three-quarters  of  an  inch; 
width,  one-half  inch,  and  thickness,  one-sixth  inch.     Practically  the  average 


of  large,  strong  nerves  for  the  vagina.  The  nerve  supply  to  the  vagina  (plexus  vaginalis), 
a  richly  ganglionated  plexus  appears  more  luxuriant,  enormous,  profound,  than  that  of  the 
uterus,  because  it  is  more  on  the  surface,  more  apparent  to  the  lens  and  unaided  eye.  The 
ganglionated  plexus  vaginalis  surrounds  the  vagina  from  the  proximal  to  the  distal  end 
with  a  mighty  netwoik,  which  in  its  richness  resembles  the  network  of  cords  surrounding  a 
rubber  ball.  The  proximal  end  and  ventral  vaginal  wall  are  the  most  richly  supplied  ;  (c) 
the  plexus  vesicalis  presents  some  six  emissions  of  large  strong  nerves  for  the  bladder 
(besides  a  large  strong  nerve  which  arises  from  the  II  sacral  and  passes  directly  to  the 
bladder.  The  bladder  is  richly  supplied  by  an  extensive  ganglionated  plexus  ;  (d)  the 
plexus  uterinus  presents  some  twelve  emissions  of  large  nerves  passing  from  the  pelvic 
brain  to  the  uterus.  With  a  lens  one  can  count  five  of  the  trunks  of  the  plexus  uterinus 
coursing  to  the  uterus  external  to  the  ureter,  and  about  seven  trunks  pass  to  the  uterus 
median  to  the  ureter.  Also  one  large  or  two  small  strands  of  nerves  pass  directly  from  the 
plexus  interiliacus  (hypogastricus)  to  the  uterus  without  first  entering  the  pelvic  brain. 

The  nerve  supply  (in  this  subject)  to  the  uterus  (plexus  uterinus),  a  richly  ganglionated 
plexus,  is  luxuriant,  enormous,  profound.  This  infant's  uterus  and  vagina  demonstrate  t?:at 
they  are  profoundly  supplied  by  a  richly  ganglionated  fine  nerve  plexus  which  is  intimately 
woven  on  their  surfaces  and  richly  distributed  through  their  parenchyma.  The  uterus, 
like  the  heart,  appears  to  possess  single  ganglia  to  rule  its  functions  should  the  local  ruler, 
the  pelvic  brain,  become  incompetent 


134  THE  ABDOMINAL  AND  PELVIC  BRAIN 

dimensions  of  the  pelvic  brain  remain  permanent,  though  the  diameters 
vary.  If  the  major  diameter  decreases  the  minor  diameter  increases,  and 
vice-versa.  Solid  coalescence  or  plexiform  distribution  of  the  ganglia  per- 
haps alters  inappreciably  the  general  number  of  ganglion  cells.  The 
thinnest  or  most  membranous  portion  is  its  proximal  segment.  The  thickest 
or  most  ganglionic  portion  of  the  abdominal  brain  lies  on  the  lateral  vaginal 
fornix.  The  pelvic  brain  (paired),  next  to  the  abdominal  brain,  is  the  largest 
and  richest  ganglion  of  the  sympathetic  and  combined;  the  two  are  almost 
equal  in  dimension  and  number  of  ganglion  cells  to  the  abdominal  brain 
(unpaired).  The  longest  diameter  of  the  pelvic  brain  courses  parallel  to  the 
rectum  and  vagina.  Proximalward  its  dimensions  decrease,  and  when  it 
meets  the  entering  efferent  nerves  from  the  hypogastric  plexus  it  is  mem- 
branous. The  largest  ganglia  are  located  in  the  central  portion  and  dim- 
inishes from  center  to  circumference.  The  diameter  of  the  nerves  and 
nerve  commissures  also  decrease  from  centre  to  borders.  Its  plexiform 
network  increases  in  the  dimensions  of  its  fenestra  from  centre  to  circum- 
ference. Ganglia  of  various  dimensions  and  form,  macroscopic  and  micro- 
scopic, are  located  adjacent  to  the  abdominal  brain.  Seldom  does  one  meet 
in  dissection  a  pelvic  brain  of  the  extensive  dimensions,  definite  contour, 
solidarity  and  compactness  of  Frankenhauser's  illustration  (1867).  I  think 
Lee's  illustration  (1841)  is  more  natural  in  dimension  and  form.  The 
macroscopic  dimensions  of  the  pelvic  brain  depends,  doubtless,  much  on  the 
dissector— deficient  or  excessive  removal  of  connective  tissue  are  frequent 
errors.  The  microscope  demonstrates  enormous  numbers  of  ganglion  cells 
in  the  pelvic  brain,  which,  combined  with  periganglionic  and  connective 
tissue,  produces  an  organ  of  significant  and  marked  dimension.  Does  the 
pelvic  brain  increase  in  dimension  during  pregnancy?  Whether  its  ganglion 
cells  increase  in  number,  multiply,  I  am  unable  to  answer.  Perhaps,  how- 
ever, I  have  satisfied  myself  by  careful  dissection  that  the  pelvic  brain  during 
gestation  macroscopically  increases  its  dimension,  whether  it  be  from 
hypertrophy,  or  hyperplasia  increase  in  vessels,  connective  tissue,  neuri- 
lemma or  muscle.  In  the  gestating  uterus  the  pelvic  brain  measures  1/4 
inches  in  length,  in  width  1  inch,  thickness  \. 

Form. — The  pelvic  brain  is  in  general  triangular,  trowel-shaped,  fre- 
quently quadrangular  in  outline.  It  is  a  more  or  less  solid,  compact,  com- 
posite or  compound  ganglion,  and  not  merely  a  nerve-meshed  network.  If 
the  surface  dimension,  contour,  increases,  the  thickness  decreases,  and  vice- 
versa,  presenting  a  widely  varied  form,  resembling  in  this  respect  the 
abdominal  brain.  With  more  recent  repeated  dissection  of  the  pelvic  brain, 
especially  on  infant  cadavers,  I  am  inclined  to  believe  the  ganglionated 
plexiform  arrangement,  the  composite,  compound  ganglion  within  its 
usual  signification,  prevails  in  the  majority  of  subjects,  explaining  the 
numerous  irregular  and  individual  forms.  The  form  is  modified  by  coales- 
cence or  separation  of  ganglia  by  the  dimension  of  the  fenestra  and  diameter 
of  the  nerve  cords  and  commissures. 

The  borders    (margo   cerebri  pelvis). — The  countour  or  borders  of  the 


ANATOMY  135 

pelvic  brain  are  not  well  denned  and  irregular.'  They  possess  projecting 
lobes  for  (afferent)  nerve  reception  and  serrated  processes  for  (efferent) 
nerve  emission.  The  thinnest  borders  are  the  proximal  and  lateral,  the 
thickest  are  distal  and  medial;  the  vast  majority  of  nerves  arrive  and  depart 
from  its  borders.  Some  arise  and  depart  from  its  surface.  Nerve  loops  may 
arise  and  insert  themselves  in  the  same  surface  as  the  abdominal  brain. 
The  nerves  are  chiefly  received  (afferent)  on  the  proximal  and  lateral  borders 
and  depart  (efferent)  from  the  median  and  distal  borders.  Practically,  how- 
ever, afferent  and  efferent  nerves  arrive  and  depart  from  both  surfaces 
and  borders  of  the  pelvic  brain.  For  convenience,  the  pelvic  brain 
may  be  described  with  four  borders;  viz.,  proximal,  distal,  median 
and  external.  The  proximal  (afferent)  border  is  of  interest  as  receiv- 
ing the  plexus  interiliacus  (hypogastricus).  The  external  border  is  important 
as  it  receives  (afferent)  the  sacral  (spinal)  nerve.  The  median  border  is 
notable  for  its  emission  (efferent)  of  the  significant  plexus  utcrinus,  plexus 
vaginalis  and  plexus  vesicalis.  The  distal  border  deserves  consideration  from 
its  emission  (efferent)  of  the  plexus  rectalis.  The  afferent  nerves  arrive 
generally  in  the  form  of  single  cords  slightly  plexiform  or  ganglionated, 
but  especially  the  efferent  nerves  depart  from  the  borders  of  the  pelvic  brain 
in  the  form  of  leashes  or  closely  meshed  ganglionated  plexuses. 

The  arrangement  of  the  pelvic  brain  consists  of  (a)  afferent  or  centrip- 
etal nerves  (entering  or  contributing  nerves)  from  the  plexus  interiliacus 
(sympathicus),  from  the  ganglia  sacralia,  from  the  sacral  (spinal)  nerves 
(uterine,  ovarian  and  round  ligament  arteries);  (b)  efferent  or  centrifugal 
(distributing  or  visceral  nerves),  known  as  plexuses.  The  afferent  nerves 
enter  chiefly  on  the  proximal  and  external  borders  as  single,  slightly  plexi- 
form, cords,  while  the  efferent  nerves  radiate  mainly  from  the  distal 
and  median  border  of  the  pelvic  brain  as  luxuriant  leashes  or  richly  gang- 
lionated plexuses.  There  is  no  relation  between  number  and  dimension  of 
the  afferent  and  efferent  nerves  of  the  pelvic  brain.  It  is  a  creating  nerve 
center;  however,  vastly  greater  numbers  of  nerves  are  efferent  (exit)  than 
afferent  (arrivals).  The  afferent  nerves  are  mostly  extended,  slightly  plexi- 
form or  ganglionated.  The  efferent  nerves  are  in  the  form  of  leashes,  highly 
plexiform  and  rich  in  ganglia.  Although  the  pelvic  brain  is  the  major 
assembling  centre  for  the  pelvic  vasomotor  (sympathetic)  nerves — practically 
the  source  of  the  genital  nerves — however,  nerves  (one  or  more)  pass  directly 
from  the  plexus  interiliacus  (hypogastricus)  to  the  uterus.  This  is  demon- 
strated with  facility  in  infant  cadavers.  Hence,  all  the  nerves  supplying  the 
uterus  do  not  first  pass  through  the  pelvic  brain.  The  pelvic  brain  consists 
of  the  coalesced  termination  of  the  vast  majority  of  (a)  plexus  interiliacus 
(hypogastricus);  (b)  nerves  from  the  ganglia  sacralia;  (c)  nerves  from  the 
ii.,  iii.,  iv.  nervi  sacralia;  (d)  plexus  arteriae  uterinae;  (e)  plexus  arteriae 
ovaricae;  (f)  plexus  arteriae  ligamenti  rotundi.  The  efferent  nerves  consist 
of  nerve  plexuses  and  leashes  emitted  to  each  pelvic  viscus.  The  following 
table  represents  the  arrangement  of  afferent  and  efferent  nerves  of  the  pelvic 
brain. 


136  THE  ABDOMINAL  AND  PELVIC  BRAIN 

Afferent  Nerves. 

1.  Plexus  interiliacus  (hypogastricus). 

2.  Rami  ganglionum  sacralium. 

3.  Rami  nervorum  sacralium. 

4.  Plexus  arterise  ovaricae. 

5.  Plexus  arteriae  uterinae. 

6.  Plexus  arteriae  ligamenti  rotundi. 

Efferent  Nerves. 

1.  Plexus  uterinus. 

2.  Plexus  ureteris. 

3.  Plexus  vesicalis. 

4.  Plexus  urethralis. 

5.  Plexus  clitoridis. 

6.  Plexus  vaginalis. 

7.  Plexus  rectalis. 

The  plexuses  of  the  pelvic  brain  radiate  to  the  tractus  genitalis  (ovary, 
oviduct,  uterus,  vagina,  clitoris);  to  the  tractus  urinarius  (bladder,  urethra); 
to  the  tractus  intestinalis  (rectum).  The  efferent  ganglionated  plexuses  and 
leashes  of  the  pelvic  brain,  of  varied  caliber,  ensheathe  and  accompany 
arteries  as  the  nerve  emissions  from  the  abdominal  brain,  but  pass  to  the 
pelvic  viscera  and  weave  through  and  around  them  a  luxuriant,  profound, 
ganglionated,  plexiform  network,  the  major  part  of  which  is  destined  for  the 
tractus  genitalis  (uterus  and  vagina).  The  nerves  emitted  by  the  pelvic 
brain  are  white  in  color,  limited  in  diameter,  plexiform  in  arrangement, 
resist  tension  on  account  of  the  powerful  fibrous  neurilemma  and  are  richly 
bedecked  with  ganglia  at  the  points  of  nerve  crossing  or  anastomosis.  The 
arrangement  of  the  pelvic  brain  produces  a  structure  consisting  of  composite 
or  an  aggregation  of  ganglia  with  nerve  commissures  or  cords. 

The  Surface. — The  surface  of  the  pelvic  brain  is  more  smooth  even  than 
that  of  the  abdominal  brain,  as  the  ganglia  and  fenestra  are  less  in  dimension. 
One  may  observe  on  its  surface  numerous  depressions,  fenestra  of  irregular 
form  and  dimension  occupied  by  strong  connective  tissue,  blood  and  lymph 
vessels.  Some  vessels  centrally  located  may  present,  emerging  through 
perforation  of  the  ganglion.  The  blood-vessels  fix  and  bind  it  to  vagina. 
Thin  strands  or  loops  of  nerves  may  be  observed  arising  and  inserting 
themselves  on  the  same  surface  of  the  pelvic  brain,  resembling  the  chordae 
tendinae  of  the  heart.  Some  smaller  nerve  strands  arrive  (afferent)  and 
depart  (efferent)  from  the  surface. 

Fenestra. — The  fenestra  of  the  pelvic  brain,  irregular  in  dimension  and 
contour,  depend  for  number  and  dimension  on  the  coalescence  or  separation 
of  the  ganglia. 

The  dimensions  of  the  fenestra  increase  from  center  to  periphery.  The 
fenestra  are  occupied  by  connective  tissue  vessels — arteries,  veins  and 
lymph.     Lymph  glands  may  also  be  found  in  them. 


ANATOMY  137 

The  color  is  whitish-gray,  brown;  a  liberal  admixture  of  white  conectiven 
tissue. 

The  consistence  is  moderately  dense  from  association  of  abundant  con- 
nective tissue. 


PELVIC  BRAIN 


Fig.  40.  An  illustration  of  the  pelvic  brain,  drawn  from  my  own  dissection.  The  plexus 
interiliacus  (hypogastricus)  is  distinct,  presenting  two  terminations — viz. :  (a)  one  part  (P) 
terminates  in  the  uterus  without  first  passing  through  the  pelvic  brain  (B).  The  other 
portion  of  the  plexus  interiliacus  terminates  in  the  pelvic  brain  (B).  The  source  of  the 
nerves  which  compose  the  pelvic  are  (a)  interiliac  plexus;  (b)  the  sacral  plexus;  (c)  the 
sacral  ganglia.  It  may  be  observed  that  there  are  small  ganglia  on  the  rectum,  bladder 
and  vagina  and  uterus.  The  pelvic  brain  rules  the  physiology  of  the  tractus  genitalis ;  it 
is  a  brain,  it  is  a  receiver,  a  reorganizer  and  an  emitter  of  nerve  force.  The  pelvic  brain 
includes  in  its  dynamics  the  initiation,  maintenance  and  conclusion  of  labor.  G.  S.,  great 
sciatic.  Pu.,  pudic  nerve.  S.  G.,  sacral  ganglia.  R.,  rectum.  V.,  vagina.  X  represents  the 
nerve  which  arises  from  the  III  sacral  and  ends  in  the  bladder.  H.,  interiliac  disc.  U.,  ureter. 
C.  I.,  common  iliac  artery.  16,  vasa,  ovarica  crossing  the  ureter.  Ov.,  ovary.  O.  D.,  oviduct. 
Observe  the  solid  ganglionic  mass  (A)  as  a  pelvic  brain.  Note  the  peculiar  origin  from 
the    sacral    nerves    and    the  tailed   division.    The  pelvic  brain  is  but  slightly  fenestrated. 


THE  ABDOMINAL  AXD  PELVIC  BRAIX 

The  Ganglia. — The  ganglia  of  the  pelvic  brain  vary  in  location,  number, 
dimension,  coalescence,  separation  and  form.  Each  ganglion  is  composed 
of  oval  or  spherical-shaped  ganglionic  nerve  cells,  ensconced  in  abundant  and 
fine  strand  white  connective  tissue.  Does  the  pelvic  brain,  the  cervical 
ganglion,  exist  as  a  constant  structure  in  every  subject?  The  answer  is  a 
positive  affirmative.  However,  the  pelvic  brain  does  not  exist  with  such 
definitely  located  and  constantly  formed  ganglia  as  that  of  the  abdominal 
brain.  The  ganglion  at  the  distal  end  of  the  major  splanchnic  nerve  cannot 
be  confused  in  constant  dimension  and  location.  It  is  a  constant,  permanent 
ganglionated  apparatus,  demonstrable  in  every  subject.  The  macroscopic 
ganglia  are  especially  numerous  adjacent  to  the  cervix  uteri.  In  the  pelvic 
brain  the  dissector  does  not  find  a  single  definitely  located  constant  ganglion 
with  exact  dimensions.  What  is  found  in  most  subjects  is  an  apparatus 
consisting  of  composite  ganglia  and  nerve  commissures  and  ganglionated 
plexus  of  irregular  form  and  uncertain  dimension,  but  practically  constant  in 
location.  The  ganglia  and  their  commissures  vary  in  dimension,  form, 
location  and  number.  It  is  a  difficult  task  and  time-robbing  process  to 
dissect  and  expose  accurately  the  ganglia  and  commissures  of  the  pelvic 
brain.  The  pelvic  brain  (the  pelvic  nerve  apparatus),  like  the  plexus  inter- 
iliacus  (hypogastricus)  and  ganglion  interiliacum  or  interiliac  nerve  disc,  has 
become  dislocated  from  the  vascular  route  (arteria  hypogastrica),  due  to 
erect  attitude  and  distalward  movements  of  the  tractus  genitalis.  A  nerve 
ganglion  may  consist  of  (a)  a  single  ganglionated  nerve  cell,  surrounded  by 
periganglionic  connective  tissue;  (b)  a  group  of  ganglion  cells,  compound 
or  composite,  surrounded  by  periganglionic  connective  tissue;  (c)  it  may 
consist  of  a  plexiform  ganglionic  mass  surrounded  by  periganglionic  tissue. 
Whether  the  nerve  ganglion  (apparatus)  be  of  a  single  ganglionic  cell,  com- 
posite ganglionic  cells  or  a  plexiform  ganglionic  mass  matters  not;  its 
function  is  identical  in  the  histologic  sense  (viz.,  reception,  reorganization 
and  emission  of  nerve  force).  In  the  composite  ganglionic  mass  of  the  pelvic 
brain  the  function  of  the  ganglia  are  not  differentiated  like  the  composite 
ganglia  of  the  cranial  brain.  The  pelvic  brain  is  a  composite  ganglion.  It 
consists  of  central  ganglia  of  larger  dimension  surrounded  by  numerous 
adjacent  ganglia  of  lesser  dimension.  The  smaller  ganglia  may  possess 
single  afferent  and  efferent  nerves.  The  pelvic  brain,  an  aggregation  of 
ganglia,  is  surrounded  with  periganglionic  tissue  only,  and  connective  tissue 
enters  with  the  nerve  tissue.  The  ganglia  of  the  pelvic  brain  coalesce  to  a 
central  more  or  less  solid  mass  and  gradually  decrease  in  dimension  toward 
the  periphery,  while  the  dimension  of  the  fenestrated  network  increase  and  the 
nerve  commissures  become  elongated  and  more  limited  in  diameter. 

The  Ganglionic  Cells. — The  ganglionic  cells  lie  in  oval  or  spherical 
spaces  of  periganglionic  tissue.  The  nerve  trunk  of  a  ganglion  will  divide 
and  reunite  between  the  ganglion  cells.  The  connective  tissue,  septa,  divide 
the  ganglion  in  departments  of  oval  or  spherical  form  which  contain  units  or 
groups  of  ganglion  cells.  The  cell  body  is  generally  granular  and  has  a  well- 
defined  central  nucleus.     The  nucleus  seldom  is  located  against  the  cell  wall 


A\AT<  ).MV 

— extra  central.     The  dimensions  of  the  ganglion  cells  vary.     The  number  of 
ganglion  cells  in  the  pelvic  brain  is  enormous. 

GENERAL  REMARKS  ON  THE  PELVIC  BRAIN. 

The  relations  of  the  pelvic  brain  is  that  it  was  primarily  an  executive 
ganglionic  nerve  apparatus  for  the  vascularity  of  the  tractus  genitalis; 
secondarily,  for  the  distal  end  of  the  tractus  urinarius  (ureter,  bladder, 
urethra) ;  thirdly,  for  the  distal  end  of  the  tractus  intestinalis  (rectum). 
At  present  in  man  it  is  a  local  executive  ganglionic  nerve  apparatus  for  the 
general  pelvic  viscera.  Cloacal  differentiation  has  resulted  in  the  more 
intimate  relations  of  the  distal  end  of  the  tractus  genitalis,  intestinalis  and 
urinarius,  with  consequent  solid  and  compact  nerve  anastomosis. 

The  relations  of  the  pelvic  brain  well  ensconced  in  connective  tissue 
are  in  intimate  connection  with  the  cervix  uteri,  lateral  vaginal  fornix, 
lateral  borders  of  rectum,  distal  ureter,  vasa  uterina,  plexus  sacralis  spinalis, 
plexus  interiliacus  (hypogastrics)  bladder.  The  pelvic  brain  is  located  at 
the  distal  end  of  the  plexus  interiliacus.  It  lies  ensconced  in  the  dense  para- 
metria! tissue  perforated  and  benetted  by  blood-vessels  and  offers  difficulties 
for  complete  exposures  by  dissection.  Nerves  arrive  (afferent)  in  the  pelvic 
brain  as  a  rule  at  the  proximal  and  lateral  borders  as  simple  cords  chiefly  and 
depart  (efferent)  mainly  from  the  distal  and  medial  borders  as  leashes  and  plex- 
uses. More  nerves  depart  than  are  received  by  the  ganglion  cervicale;  hence, 
it  is  an  originating,  a  creating  center,  a  source  of  new  nerve  strands.  The 
pelvic  brain  is  a  constant  structure.  It  is  always  a  multiple  or  composite 
ganglionic  apparatus.  It  receives  both  spinal  and  sympathetic  nerves.  The 
origin  of  the  nerves  contributed  to  the  pelvic  brain;  the  afferent  are:  (1) 
plexus  interiliacus  (hypogastrics) ;  (2)  ganglia  lumbalis;  (3)  plexus  hemor- 
rhoidals; (4)  ganglia  sacralia;  (5)  i,  ii,  iii,  iv  nervi  sacralis  spinales.  The 
converging  nerves  which  coalesce  to  form  the  pelvic  brain,  a  composite 
ganglion,  are  both  sympathetic  (dominating)  and  spinal  (subordinate).  All 
efferent  nerves  of  the  pelvic  brain  are  vasomotor  (sympathetic).  The 
cervical  ganglion  demedullates  the  spinal  nerves,  hence  all  exit  efferent 
nerves  are  sympathetic.  The  vast  majority  of  the  nerves  enter  the  borders 
of  the  ganglion  cervicale;  some  enter  its  surface.  The  efferent  nerves  of  the 
pelvic  brain  compose  (1)  plexus  uterinus,  the  main  rich  ganglionated  nerve 
supply  of  the  uterus — the  plexus  interiliacus  (hypogastrics)  sends  some 
nerves  to  the  uterus  which  do  not  first  pass  through  the  pelvic  brain  (see 
Fig.  1) ;  (2)  plexus  vesicalis,  a  rich  plexiform  network  studded  with  ganglia 
(the  iii  spinal  sacral  nerve  emits  a  large  branch  which  courses  on  the  lateral 
border  of  the  rectum  and  vagina  to  supply  the  bladder;  thus,  the  vesical 
nerve  supply  is  a  mixed  spinal  and  sympathetic,  hence  obscuring  the  vesical 
peristalsis) ;  (3)  plexus  vaginalis,  supplying  the  vagina  with  an  abundant, 
mighty,  woven  nervous  network  studded  with  ganglia;  (-4)  plexus  rectalis,  a 
network  of  nerves  vastly  less  rich  than  either  the  plexus  vesicalis  or  plexus 
vaginalis  with  ganglionated  masses  at  the  points  of  nerve  strand  coalescence ; 
(5)  plexus  clitoridis,  a  rich  and  luxuriant  ganglionated  plexus  supplying  the 


140  THE  ABDOMINAL  AND  PELVIC  BRAIN 

clitoris  with  an  enormous  quantity  of  nerves.  The  additional  discoveries  of 
increased  numbers  of  microscopic  nerve  in  the  uterus  (Jung,  Koch,  Kerner) 
only  further  established  the  principle  which  I  advocated  fifteen  years  ago — 
viz.,  that  "automatic  visceral  ganglia  exist  in  every  organ — e.g.,  I  advocated 
a  decade  and  a  half  past  this  principle  and  introduced  the  terms  automatic 
menstrual  ganglia,  automatic  vesical  ganglia,  automatic  renal,  splenic  and 
hepatic  ganglia.  The  composite  compound  ganglia  of  the  pelvic  brain  are  all 
identical  in  function  (rhythm) — unlike  the  differentiated  function  of  the  com- 
posite ganglia  of  the  cranial  brain.  No  parts  of  the  pelvic  cellular  tissue 
remains  free  from  traversing  nerves  and  ganglia.  It  is  not  only  the  subser- 
osium  paracervicale  and  paravaginale  immediately  adjacent  to  the  uterus 
and  vagina  that  is  richly  traversed  with  gangliated  nerves,  but  also  the 
distant  lateral  subserous  pelvic  cellular  tissue  is  abundantly  supplied  with 
the  same  nerve  apparatus,  however  attenuated.  The  central  pelvic  visceral 
apparatus  (tractus  genitalis)  ovary,  uterus,  oviducts  and  vagina,  is  richly  and 
luxuriantly  surrounded  with  a  ganglionate  nerve  plexus  resembling  the  net- 
work enclosing  a  rubber  bulb.  This  wonderful  wealth  of  ganglionated 
genital  sympathetic  nerves  I  have  so  far  been  enabled  to  observe  on  infant 
cadavers  only  and  by  the  aid  of  a  magnifying  lens.  Gross  dissection  of 
adults  baffles  observation.  My  dissections  have  convinced  me  that  the 
pelvic  brain  in  general  subjects  is  not  so  compact  a  ganglion  nor  so  pro- 
nounced in  contour  as  claimed  by  Frankenhauser  in  his  illustration  of  1867, 
which  I  think  is  exaggerated  in  dimension,  compactness  or  solidarity  and  in 
its  definiteness  of  contour  or  borders.  The  pelvic  brain  is  difficult  of  prep- 
aration because  of  its  resemblance  to  adjacent  connective  tissue  in  structure 
and  color.  It  is  whiter  than  the  abdominal  brain.  To  observe  correct  rela- 
tions the  pelvic  brain  must  be  dissected  in  situ.  The  most  complete  observa- 
tions of  the  pelvic  brain  is  obtained  from  infant  cadavers  preserved  in  alcohol, 
in  which  little  dissecting  preparation  is  required  and  the  cellular  tissue  is 
transparent  whence  the  nerves,  together  with  their  branches  and  ganglia,  the 
pelvic  brain,  are  distinctly  visible  and  extraordinarily  instructive.  This 
method  avoids  the  errors  arising  during  gross  dissection  of  the  pelvic  brain 
in  adults.  The  pelvic  brain  (ganglion  cervicale)  is  a  constant  ganglionated 
anatomic  structure.  It  is  practically  complete  in  the  infant  as  to  form  and 
location,  however;  its  ganglia  and  periganglionic  tissue  develops  with  the 
development  of  the  arteria  uterina  and  genital  functions  (menstruation  and 
gestation).  Its  dimensions  and  form  varies  within  wide  limits.  The  pelvic 
brain  represents  the  major  ganglionic  assembling  center  of  the  pelvic 
(genital)  nerves.  It  is  particularly  the  coalescing  termination  of  the  nerves 
of  the  tractus  genitalis.  Investigators  agree  as  to  the  pelvic  brain  being  a 
ganglion  in  animals,  but  opinions  diverge  as  to  whether  it  is  a  ganglion  or 
plexus  in  man.  Remak  demonstrated  in  the  pig  (1841)  the  presence  of 
ganglia  on  the  nerve  trunks  which  course  to  either  side  of  the  uterus.  I 
have  found  it  a  slight  task  to  dissect  and  definitely  expose  the  pelvic  brain  in 
animals  in  which  it  is  more  distinctly  an  isolated  single  ganglion.  The  rela- 
tions of  the  pelvic  brain  to  the  abdominal  brain  is  subordinate  in  function 


A.\.\T()\!Y  111 

and  location,  similar  to  the  relations  of  the  cerebellum  to  the  cranial  cere- 
brum;  hence,  it  might  be  termed  the  cerebellum  sympathicum.  The  pelvic 
brain  is  the  nerve  executive  apparatus  of  the  pelvic  organs — especially  the 
tractus  genitalis.  The  pelvic  brain  is  always  a  ganglionate  plexus.  The 
degree  of  ganglionic  coalescence  or  isolation  decides  its  unity  or  multiplicity 
— its  ganglionic  or  plexiform  state.  Through  the  pelvic  brain  the  nerves  of 
the  distal  end  of  the  tractus  urinarius,  genitalis,  intestinalis  are  solidly  and 
compactly  anastomosed,  connected.  Hence,  irritation  of  one  of  the  three 
tracts  will  irritate,  induce  reflexes  in  the  other  two  (as  in  operation).  The 
pelvic  brain  is  the  ganglionic  automatic  nerve  apparatus  of  the  uterus. 
Together  with  the  ganglia  located  in  the  uterus  it  is  the  automatic  nerve 
center  of  the  uterus.  It  is  a  composite  ganglionic  apparatus  interpolated 
between  the  cerebrospinal  center  and  the  myometrium — the  uterus.  About 
the  year  1863  microscopic  ganglia  were  discovered  in  the  walls  of  the  uterus 
and  vagina  by  Keher,  Koerner  and  Frankenhauser — which  I  termed  automatic 
visceral  ganglia  fifteen  years  ago.  The  ganglionic  theory  of  an  automatic 
nerve  center  in  the  uterus,  similar  to  that  of  the  heart,  intestine,  bladder, 
ureter,  has  a  rational  anatomic  base.  Experiments  first  demonstrated  that 
the  muscle  of  the  uterus  (myometrium)  was  irritable — would  contract  and 
relax,  was  rhythmic — after  death.  Observation  demonstrated  that  children 
were  born,  expelled,  after  the  death  of  the  cerebrospinal  axis.  In  short,  the 
uterus  is  subject  to  rhythmic  movements  a  certain  length  of  time  subsequent 
to  death  or  extirpation  precisely  similar  to  that  of  the  other  visceral  tracts; 
viz.,  tractus  intestinalis  (gastrium,  enteron  colon);  tractus  urinarius  (ureter, 
bladder);  tractus  vascularis  (heart,  aorta);  tractus  genitalis  (oviduct,  uterus). 
It  is  well  known  that  segments  of  the  involuntary  muscles  of  the  visceral 
tracts  dominated  by  the  sympathetic  may  persist  in  rhythmic  movements, 
accompanied  or  not  by  artificial  stimulation.  It  is,  doubtless,  due  to  a  local- 
ized peripheral  nerve  apparatus — automatic  visceral  ganglia — located  in  the 
parenchyma  of  the  organs  possessing  a  partially  independent  and  more  per- 
sistent life  than  that  of  the  cerebrospinal  apparatus.  The  pelvic  brain  is  the 
ganglionic  automatic  nerve  apparatus  for  the  uterus,  subordinate  in  number 
of  ganglion  cells  to  the  abdominal  brain,  and  consequently  subordinate  in 
power.  There  is  a  genital  center  in  the  lumbar  cord  which,  being  irritated, 
induces  uterine  contraction.  This  center  is  of  limited  importance  and  sub- 
ordinate to  the  sympathetic  peripheral  center.  The  lumbar  center  is  not 
absolutely  necessary  for  conception,  gestation  and  parturition,  as  these  proc- 
esses will  occur  when  the  sacral  nerves  which  supply  the  uterus  are  severed. 
To  say  that  the  pelvic  brain  is  the  automatic  nerve  center  for  the  uterine 
vessels  simply  is  to  beg  the  question,  for  it  is  the  blood  that  stimulates  the 
myometrium  (or  any  other  organ)  to  contraction.  The  peripheral  gangli- 
onic nerve  apparatus  of  the  uterus  (including  the  pelvic  brain),  macro- 
scopic and  microscopic,  is  the  principal  nerve  center  for  its  innervation. 
The  pelvic  brain  (paired)  located  bilaterally  at  the  cervico-vaginal  junction 
is  solidly  and  compactly  anatomosed,  connected,  by  a  profoundly  rich  gan- 
glionated  network  of  nerve  plexuses.     The  pelvic  brain  is  the  localized,  sub- 


142  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

conscious,  vegetative,  sympathetic,  automatic  nerve  apparatus  for  the 
organic  life  of  the  pelvic  viscera,  particularly  of  the  tractus  genitalis. 

The  pelvic  brain  is  located  closely  adjacent  to  the  point  of  crossing  of 
the  ureter  by  the  pelvic  floor  segment  of  the  utero-ovarian  artery,  hence  in 
hysterectomy  the  cervical  ganglion  is  extensively  traumatized  and  damaged. 

A  curious  feature  in  regard  to  the  pelvic  brain  is  that,  however,  origin- 
ally it  was  a  vascular  brain,  located  intimately  with  the  common  iliac  arteries, 
at  present  in  man  from  erect  attitude  and  distalward  movements  of  the 
tractus  genitalis,  it  is  practically  removed  from  great  arteries  and  lies 
ensconced  in  a  woven  web  of  rich  veins.  The  largest  ganglia  of  the  pelvic 
brain  lie  in  the  center,  while  extending  to  widely  adjacent  distances  on  the 
viscera  are  located  smaller  ganglia,  separated  by  gradually  increasing 
fenestrated  areas. 

The  nerve  plexuses  and  accompanying  ganglia  of  the  pelvic  brain  firmly 
bound  in  connective  and  elastic  tissue  richly  surround  the  tractus  genitalis 
like  a  net  on  a  rubber  ball  and  traverse  its  parenchyma  like  a  spider's  web. 

In  the  rich  ganglionated  plexuses  issuing  from  the  pelvic  brain  to  the 
tractus  genitalis,  i.e.  the  periuterine  and  parauterine  plexuses,  as  well  as  the 
perivaginal  and  paravaginal  plexuses,  the  nerves  assume  an  arrangement 
similar  to  the  arterial  blood-vessels,  i.e.  they  decrease  in  dimension  in  the 
median  plane.  The  entire  uterus  is  luxuriantly  surrounded  and  its  paren- 
chyma richly  traversed  by  abundantly  gangliated  nerve  networks. 

The  vagina  from  proximal  to  distal  ends  is  interwoven  with  a  fine 
network  of  nerve  fibers  interspersed  with  ganglia  to  a  remarkable  degree. 
(Best  observed  with  a  magnifying  lens  in  infant  cadavers.) 

The  pelvic  brain  receives,  reorganizes  and  emits  nerve  forces  and  hence 
is  not  a  mere  agent  of  the  spinal  cord.  In  it  are  repeated  physiologic  and 
pathologic  manifestations  of  general  visceral  functions  (rhythm,  absorption 
and  secretion)  and  special  visceral  function  of  the  tractus  genitalis  (ovulation, 
menstruation  and  gestation). 

The  pelvic  brain  is  subordinate  in  function  to  the  abdominal  brain 
because  of  less  number  of  cells  only,  while  it  is  superior  in  specialized 
function  (as  ovulation,  menstruation  and  gestation).  The  subordination  of 
the  pelvic  brain  to  the  abdominal  brain  is  evident  from  the  fact  that 
animals  and  men  can  live  well  with  the  pelvic  brain  extirpated  {i.e.  with 
absent  genital  function  or  genitals)  while  life  will  not  continue,  or  at  least 
under  disturbance  and  for  short  duration,  with  the  abdominal  brain  extir- 
pated. (The  extirpation  of  the  abdominal  brain  is  practically  an  anatomic 
inaccessibility  during  life.) 

It  must  be  admitted  from  anatomic  facts  that  the  abdominal  brain  partly 
rules  the  physiology  of  the  tractus  genitalis,  one  (or  several)  strong  nerves 
from  the  plexus  interiliacus  (directly  from  the  abdominal  brain)  passes 
directly  to  the  uterus  without  first  passing  through  the  pelvic  brain.  How- 
ever, the  plexus  uterinus,  the  major  nerve  supply  of  the  uterus — passes 
directly  from  the  pelvic  brain  to  the  uterus.  It  is  a  large,  powerful 
ganglionated  nerve  plexus  and  no  doubt  accounts  chiefly  for  the  wonderful 


ANATOMY 


143 


periodic  rhythm,  the  stately  peristalsis  of  the  uterus.     In  short,  the  individual 
functions  of  the  pelvic  brain  are: 

(1)  It    demedullates    nerves;     nerves    enter    it    (afferent)    sheathed    and 
depart  (efferent)  unsheathed. 

(2)  It  is  a  source  of  new   nerves;    it   has  more  efferent    than    afferent 
nerves. 

(3)  The  pelvic  brain  is  a  giant  vasomotor  center  for  the  pelvic  viscera 
— especially  the  tractus  genitalis. 

(4)  It   shares  in  executing  the  six  functions  of  the    tractus   genitalis— 
ovulation,  secretion,  absorption,  peristalsis,  menstruation  and  gestation. 

(5)  It  is  the  major  pelvic  reflex  center. 


FIG.    3. — PELVIC    BRAIN    OF    ADULT. 

PELVIC  BRAIN  OF  AN  ADULT 

Fig.  41.  Drawn  from  my  own  dissection.  A.,  pelvic  brain.  In  this  case  it  is  a 
ganglionated  plexus  possessing  a  wide  meshwork.  Also  the  pelvic  brain  is  located  well 
on  the  vagina,  and  the  visceral  sacral  nerves  (pelvic  splanchnics)  are  markedly  elongated. 
V.,  vagina.  B.,  bladder.  O.,  oviduct.  I't.,  uterus.  Ur.,  ureter.  R.,  rectum.  P.  L..  plexus 
interiliacus  (left).  P.  R..  plexus  interiliacus  (right).  N.,  sacral  ganglia.  Ur.,  ureter  severed 
ro  expose  the  pelvic  brain.  5  L,  last  lumbar  nerve.  I,  II,  III,  IV,  sacral  nerves.  5,  coccyg- 
eal nerve.  Observe  that  the  great  vesical  nerve  (P)  arises  from  a  loop  between  the  II  and 
III  sacral  nerves.     G.  S.,  great  sciatic  nerve. 


144  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(6)  It  possesses  nutritive  powers  over  its  peripheral  nerves.  It  presides, 
though  subordinately,  over  the  rhythm,  peristalsis,  of  involuntary,  visceral 
muscles  of  the  pelvis.  It  controls  secretion  and  absorption  of  the  glands  in 
tubular  viscera  (pelvic).  The  parametrium  and  entire  pelvic  subperitoneal 
tissue  is  richly  traversed  by  nerves  radiating  to  and  from  the  pelvic  brain. 
An  accurate  and  comprehensive  knowledge  of  the  anatomy  of  the  nerve 
supply  of  the  tractus  genitalis  (especially  the  pelvic  brain)  will  enable  the 
gynaecologist  to  interpret  symptoms  of  disease  and  to  form  a  correct  diag- 
nosis which  is  the  basis  of  rational  treatment.  It  will  aid  to  extend  so-called 
medical  gynaecology  which  is  constructive,  and  limit  so-called  surgical 
gynaecology  frequently  destructive. 

A  general  view  of  the  pelvic  brain  is  that  it  is  an  intermediary  agent 
to  receive  and  modify  the  spinal  and  sympathetic  nerve  forces  for  utilization 
in  the  tractus  genitalis.  It  is  a  plenary  envoy,  an  ambassador  plenipoten- 
tiary to  reconcile  the  spinal  and  sympathetic  forces  for  appropriate  use  in 
the  genital  tract  and  associated  viscera. 

(i>)  Physiology  of  the  Pelvic  Brain. 

The  function  of  the  ganglion  cervicale — pelvic  brain — is  practically  (a) 
to  rule  the  physiology  of  the  tractus  genitalis  (uterus,  oviduct,  ovary, 
vagina);  (b)  part  of  the  tractus  urinarius  (bladder,  distal  ureter);  (c)  part 
of  the  tractus  intestinalis  (rectum).  The  pelvic  brain,  subordinate  to  the 
abdominal  brain,  dominates  the  function  of  the  tractus  genitalis,  which  is 
under  the  command  of  the  sympathetic.  The  dynamics  of  the  pelvic  brain 
comprise  the  physiology  of  the  tractus  genitalis,  which  is: — (a)  ovulation; 
(b)  secretion;  (c)  absorption ;  (d)  peristalsis;  (e)  menstruation;  (f)  gestation 
(post-natal).  It  is  claimed  that  the  pelvic  brain  demedullates,  unsheaths, 
the  spinal  nerves  and  that  all  efferent  or  exit  nerves  of  the  ganglion  cervicale 
are  sympathetic.  The  pelvic  brain  dominates  the  pelvic  viscera  as  the 
abdominal  brain  dominates  the  abdominal  viscera.  It  assumes  the  dignity 
of  a  brain  from  its  power  of  reception,  reorganization  and  emission  of  nerve 
force.  The  dynamics  of  the  pelvic  brain  includes  the  initiation,  maintenance 
and  conclusion  of  rhythm  (peristalsis,  labor)  in  the  tractus  genitalis  as  well 
as  the  domination  of  secretion  and  absorption.  The  pelvic  brain  presides 
over  the  monthly  explosions,  monthly  rhythm  of  menstruation,  controlling  or 
modifying  the  automatic  menstrual  ganglia.  The  pelvic  brain  is  a  giant  vaso- 
motor center  (cerebrum  vasculare)  for  the  tractus  genitalis  ruling  the  vast 
and  varying  phases  of  circulation  (congestion  and  anaemia  during  sexual  life, 
as  pueritas,  pubertas,  menstruation,  gestation,  puerperium,  climacterium  and 
senescence).  It  presides  over  the  lymphatic  circulation  and  nourishment  of 
the  genital  tract.  The  pelvic  brain  rules  the  manifest  stately,  periodic 
rhythm  of  the  uterus  during  labor.  It  is  the  rhythmic  center  for  the  tractus 
genitalis.  The  pelvic  brain  dominates  the  bladder  sufficiently  to  impose  on 
it  a  rhythm  (diastole  and  systole),  however,  powerful  spinal  nerves  are  amply 
present  to  modify  the  vesical  rhythm.  The  plexus  rectalis  emitted  from  the 
pelvic  brain  to  the  rectum  to  a  limited  degree  influences  the  rhythm,  secretion 


PHYSIOLOGY  115 

and  absorption  of  the  rectum.  Cerebrum  pelvicum — the  ganglion  cervicale 
—is  an  automatic  nerve  center,  a  brain,  as  it  has  the  power  of  reception, 
reorganization  and  emission  of  nerve  force. 

The  pelvic  brain  is  the  local  central  potentate  of  visceral  rule  in  the 
lesser  pelvis. 

The  initiation,  maintenance  and  conclusion  of  parturition  should  be 
referred  to  the  pelvic  brain.  The  stately  rhythm  and  measured  peristalsis  of 
the  uterus  in  the  evacuation  of  its  contents  has  excited  the  wonder  and  stirred 
the  profound  amazement  of  all  observers  in  all  time.  The  rhythm  of  the 
uterus  is  its  protest  'against  all  occupants.  The  gestating  uterus  is  always 
in  a  state  of  rhythm— the  most  active  when  most  distended.  The  uterus 
(corpus  and  fundus)  is  always  ready  for  an  abortion.  Were  it  not  for  the 
guarding,  resting  cervix,  the  sentinel  of  the  uterine  portals,  the  continuous 
myometrial  rhythm  would  expel  all  uterine  contents  without  regard  to  time. 
In  the  resting  uterus  the  cervical  ganglion  or  pelvic  brain  is  free  from 
pressure,  not  subject  to  trauma.  In  the  gestating  uterus,  since  the  cervix  is 
not  practically  involved  in  the  enlargement,  distention,  the  cervical  ganglion 
is  free  from  pressure  or  trauma  because  the  gestating  corpus  and  fundus  pass 
proximalward  in  the  abdomen  in  the  direction  of  the  least  resistance,  for 
ample  space,  leaving  the  lesser  pelvis  free  from  compromising  pressure  or 
trauma  as  in  the  resting  uterus.  During  the  last  month  of  gestation  the 
fetus  (especially  the  head  or  perhaps  the  pelvis)  passes  distalward  into  the 
lesser  pelvis  and  gradually  the  cervix  becomes  distended,  obliterated  from 
pressure,  allowing  the  fetal  parts  (head  or  pelvis)  to  press,  traumatize, 
mechanically  irritate  the  pelvic  brain  with  gradually  increasing  intensity, 
which  initiates  labor  (uterine  rhythm). 

Pressure  or  trauma  of  the  cervical  ganglion  incites  the  vigor  and  fre- 
quency of  the  uterine  rhythm  which  is  practically  painless,  however,  the 
traumatism  or  stretching  of  the  spinal  nerves  supplying  the  cervix,  vagina 
and  pudendum  makes  labor  painful.  Practically  the  vast  majority  of  the 
plexus  uterinus  or  uterine  nerves  originate  in  the  pelvic  brain;  hence,  for 
the  control  of  uterine  haemorrhage  the  cervical  ganglion  must  be  consulted. 
In  certain  cases  of  postpartum  haemorrhage  the  older  obstetricians  claimed 
that  by  compressing  the  aorta  the  haemorrhage  was  checked.  This,  of 
course,  was  an  error,  as  its  effective  technical  execution  is  practically 
impossible.  The  vasa  ovarica  are  not  affected  by  the  method.  The  manip- 
ulation on  the  walls  of  the  abdomen  stimulated  the  plexus  aorticus  and 
plexus  hypogastricus  which  transmitted  the  stimulus  to  the  pelvic  brain 
where  it  was  reorganized  and  emitted  over  the  plexus  uterinus  to  the 
myometrium — the  elastic  and  muscular  bundles  of  which  under  its  control 
act  like  living  ligatures — checking  the  bleeding.  Again,  certain  cases  of 
post-partum  haemorrhage  are  fatal.  The  explanation  may  be  that  the 
trauma  of  labor,  especially  the  child's  head,  may  have  partially  paralyzed  the 
pelvic  brain  (and  interiliac  plexus),  whence  the  control  of  the  muscular  and 
elastic  bundles  in  the  myometrium  is  lost — they  become  relaxed  and  fail  to 
contract  the  vascular  lumen.     In  post-partum  haemorrhage  four  procedures 


146  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

are  indicated: — First,  rapid,  light  stroking  of  the  abdomen  parallel  to  the 
plexus  aorticus  and  plexus  interiliacus,  the  effect  of  which  is  to  stimulate 
both  abdominal  and  pelvic  brain.  Second,  seize  the  uterine  fundus  through 
the  abdominal  wall  and  massage  it,  whence  irritation  of  the  myometrium 
induces  its  peripheral  ganglia  (automatic  menstrual  ganglia  located  in  the 
myometrium  and  the  pelvic  brain  located  at  the  cervico-vaginal  junction)  to 
contract  the  vascular  walls,  lessening  the  blood  currents.  Third,  introduce 
the  finger  into  the  vagina  at  the  lateral  fornix  and  excite  the  pelvic 
brain,  which  will  emit  a  stimulus  over  the  plexus  uterinus  to  the  myometrium 
resulting  in  the  contraction  of  its  elastic  and  muscular  bundles.  Fourth, 
intra-uterine  digital  irritation  stimulates  the  pelvic  brain  through  the  peri- 
pheral ganglionated  nerve  plexuses  which  limits  the  vascular  lumen. 

The  pelvic  brain  initiates,  sustains  and  concludes  parturition  (peristalsis, 
labor).  Alexander  Keilmann's  theory  of  the  introduction  of  labor  (1881) 
through  mechanical  irritation,  pressure,  or  trauma  of  the  pelvic  brain  is  the 
most  rational  as  it  is  supported  by  anatomic  and  physiologic  data.  The 
more  mechanical  irritation  by  the  fetal  pressure  the  greater  the  number  of 
ganglia  of  the  pelvic  brain  are  excited,  traumatized;  hence,  with  distal  ward 
movement  of  the  child  the  labor  is  intensified  in  a  geometrical  ratio. 

The  more  distahvard  the  child  passes  the  more  nerve  elements  are 
traumatized.  When  the  head  of  the  child  rests  on  the  pelvic  floor,  it 
practically  presses,  traumatizes  or  mechanically  irritates  all  the  pelvic  nerve 
elements  (ganglia),  hence  parturient  peristaltic  pains  are  vigorous. 

The  finger  introduced  in  the  rectum  can  irritate  the  pelvic  brain  with 
facility,  which  jeopardizes  the  patient  less  as  regards  infection.  Hot 
vaginal  douches  stimulate  uterine  peristalsis  in  labor.  The  uterus  itself 
may  be  considered  a  center  with  an  automatic  nerve  apparatus  (as  I 
advocated  in  1^90,  automatic  menstrual  ganglia).  This  idea  of  partial 
automatic  nerve  apparatus  being  located  in  the  uterus  itself  is  heightened 
by  observation  that  the  uterus  is  the  most  vigorously  rhythmic  in  the  begin- 
ning and  ending  of  gestation.  Goltz  claims  that  a  genital  center  is  located 
in  the  lumbar  cord,  which  has  practically  demontsrated  itself  as  true  on 
humans  from  injuries  to  the  spinal  cord.  Goltz  severed  the  spinal  cord  at 
the  level  of  the  tenth  and  eleventh  dorsal  vertebra  on  a  dog  and  witnessed 
normal  conception  and  parturition,  hence  he  concluded  that  a  genital  center 
is  located  in  the  lumbar  cord.  The  confusion  would  here  lie  in  the  influenc- 
ing connection  of  the  vagi  with  the  abdominal  brain.  Does  Goltz's  genital 
center  in  the  lumbar  cord  explain  the  common  pain  in  the  back  in  disease  of 
the  female  genitals?  Rein  severed  the  sympathetic  system  and  sacral  nerves 
supplying  the  uterus,  but  subsequently  normal  conception  and  paturition 
occurred  in  the  dog.  Finally  Rein  claimed  that  he  severed  all  the  sympa- 
thetic nerves  to  the  uterus  as  well  as  the  sacral  nerves  and  extirpated  the 
pelvic  brain  (bilaterally)  and  still  a  normal  parturition  occurred  in  a  dog  four 
days  post  operation.  Hence  he  concluded  the  uterus  possessed  a  central 
nerve  apparatus  which  controls  its  own  function  (especially  peristalsis). 
This  experiment  is   defective  and  the  consequent  conclusion   erroneous  for 


PHYSIOLOGY  117 

one  can  neither  sever  all  the  sympathetic  nerves  to  the  uterus  nor  extirpate 
all  the  pelvic  brain  in  the  living  as  the  ganglionated  plexiform  network  is  too 
extensive.  It  is  an  anatomic  impossibility.  Besides  Rein  denies  the 
existence  of  a  ganglion  cervicale,  placing  in  its  stead  plexus  nervosus 
fundamentalis  uteri.  Also  Rein  overlooked  the  extensive  ganglionated 
nerve  connection — plexus  ovaricus — through  the  ligamentum  latum  from  the 
ganglion  ovaricum.  He  who  has  once  observed  with  a  magnifying  lens  the 
wealthy  labyrinth  of  luxuriant  ganglionated  nerve  plexuses  supplying  the 
tractus  genitalis  (in  the  infant)  knows  how  futile  it  would  be  to  attempt  to 
sever  all  the  nerves  of  the  uterus.  Many  authors  (Ellinger,  Rein,  Dembo, 
Cohnstein,  Byron  Robinson)  have  assumed  a  central  nerve  apparatus  located 
in  the  pelvic  brain  or  in  the  uterus.  (Similar  to  the  automatic  visceral 
ganglia  located  in  the  tractus  intestinalis,  urinarius,  heart,  etc.,  etc.)  The 
extirpated  uterus  placed  in  warm  normal  salt  solution  will  perform  its 
rhythm  for  some  time  similar  to  the  extirpated  oviduct,  ureter,  heart, 
intestine — each  has  a  partial  independent  nerve  center — automatic  visceral 
ganglia.  The  so-called  uterine  inertia,  or  sudden  cessation  of  uterine 
peristalsis  during  a  long,  slow  journey  of  the  head  through  the  pelvis  may 
be  caused  by  a  partial  paralysis  of  the  myometrium  due  to  the  temporary 
impinging  of  the  head  on  the  plexus  interiliacus  (hypogastricus)  or  pelvic 
brain.  I  observed  once  during  the  reduction  of  an  invaginated  puerperal 
uterus  of  twenty  hours'  duration  that  immediately  after  reduction  the 
blood  oozed  abundantly  from  the  uterine  mucosa  although  I  held  my  hand 
within  the  uterine  cavity.  Gradually  as  I  irritated  the  endometrium  the 
haemorrhage  lessened  and  finally  in  fifteen  minutes  ceased.  The  explanation 
was  the  trauma  or  constriction  at  the  neck  of  the  uterus  had  partially 
paralyzed  the  pelvic  brain  and  its  plexuses,  and  it  required  some  time  to 
recover  their  power  over  the  elastic  and  muscular  bundles  of  the  myome- 
trium. In  slow  labors  accompanied  by  uterine  inertia  the  pelvic  brain  could 
be  stimulated  digitally  per  rectum  or  by  rectal  clysters  or  electricity,  induc- 
ing more  frequent  and  vigorous  contractions  of  the  myometrium.  The  same 
physiologic  principle  is  involved  in  the  observation  that  violent  diarrhoea  is 
frequently  followed  by  premature  parturition  or  abortion.  Drastic  cathar- 
tics will  produce  violent  uterine  peristalsis  sufficient  to  cause  premature 
parturition  or  abortion — the  pelvic  brain  is  irritated  per  rectum.  This 
clinical  fact  demonstrated  that  the  nerves  of  the  tractus  genitalis  and 
intestinalis  are  solidly  and  compactly  anastomosed.  The  methods  to  utilize 
the  physiology  of  the  pelvic  brain  in  practice  are  varied.  For  example,  the 
mammary  gland  is  connected  to  the  pelvic  brain  by  at  least  three  distinct 
routes,  viz. :  (1)  via  the  nerve  plexuses  accompanying  the  arteria  mammaria 
and  arteria  subclavia,  whence  the  route  is  direct  along  the  aorta  and  its 
plexuses  to  the  pelvic  brain ;  (2)  via  the  nerve  plexuses  accompanying  the 
arteriae  intercostales  to  the  aorta,  whence  the  route  is  direct  over  the  aorta 
and  its  nerve  plexuses  to  the  pelvic  brain;  (3)  via  the  nerve  plexuses  accom- 
panying the  arteria  epigastrica  superior  and  inferior  to  the  common  iliac 
artery,  whence  the  route  continues  on  the  plexuses  accompanying  the  arteria 


148  THE  ABDOMINAL  AND  PELVIC  BRAIN 

rotundi  ligamenti  to  the  plexus  uterinus  (and  to  the  pelvic  brain).  There- 
fore, by  stimulating  or  irritating  the  nipple  with  light  friction  or  massaging 
the  mammary  gland  (especially  the  nipple),  the  uterus  can  be  reached  by  the 
above  routes  and  induced  to  contract  more  frequently  and  if  the  experiment 
be  not  too  rapidly  repeated  the  uterine  contractions  become  more  vigorous. 
I  have  experimented  on  this  physiologic  phenomenon  during  labor  so  frequent 
with  such  constant  results  that  no  doubt  exists  as  to  its  correctness.  The 
reverse  physiology  of  the  stimulation  of  the  genitals  influencing  the  mammae 
through  the  sympathetic  routes  from  the  genitals  to  the  mammas  are  still 
more  evident  and  frequent.  If  the  tractus  genitalis  be  stimulated  by  preg- 
nancy, uterine  myoma  or  other  genital  irritation,  the  mammary  glands 
rapidly  manifest  disturbance  in  dimension,  circulation,  color,  sensation, 
palpation.  The  sensations  in  the  tractus  genitalis  have  been  reorganized 
in  the  pelvic  brain  and  emitted  over  the  several  nerve  routes  to  the  mammary 
glands.  Again  the  uterus  may  be  incited  to  more  vigorous  and  frequent 
contraction  during  labor  by  the  administration  of  a  tablespoonful  of  hot 
water  which  first  emits  the  stimulation  over  the  plexus  gastricus  to  the 
abdominal  brain,  where  it  is  reorganized  and  transmitted  over  the  plexus 
aorticus  and  plexus  interiliacus  (hypogastricus)  to  the  pelvic  brain,  whence 
reorganization  and  emission  over  the  plexus  uterinus  occurs  with  consequent 
contraction  of  the  myometrium.  The  pelvic  brain  must  explain  the 
normal  and  abnormal  pains  of  the  uterus  as  its  dominating  nerve  center.  A 
knowledge  of  the  pelvic  brain  with  its  multiple  radiating  nerve  leashes  and 
plexuses  is  not  only  valuable  for  the  science  alone  of  obstetrics  and  gynae- 
cology, but  it  is  important  for  successful  practice.  The  independence  of 
the  pelvic  brain  is  evident  when  children  are  born,  expelled,  from  the  uterus 
after  the  death  of  the  mother.  Joseph  Hyrtl,  the  celebrated  Viennese 
anatomist,  reports  that  during  a  war  in  Spain  some  bandits  hanged  a  preg- 
nant woman.  After  she  had  hung  on  the  gallows  for  four  hours,  and 
consequently  was  long  dead,  she  gave  birth  to  a  living  child.  I  have 
observed  the  giant  uterus  of  slaughtered  pregnant  cows  executing  with  won- 
drous precision  its  stately  rhythm  and  measured  peristalsis  hours  subsequent 
to  death  and  evacuation  of  the  uterine  contents.  If  one  extirpate  an 
oviduct  from  a  human  patient  and  place  it  in  warm  normal  salt  solution 
oviductal  rhythm  may  be  maintained  by  physical  stimulus  for  some  three- 
quarters  of  an  hour.  Labor  should  be  painless,  as  normal  visceral  rhythm  is 
painless.  Scanzoni  reports  a  woman  paralyzed  from  the  dorsal  vertebra 
distalward  as  having  had  a  painless  labor — the  spinal  nerve  of  the  tractus 
genitalis  was  paralyzed — hence,  painless  dilatation  of  the  cervix  occurred, 
with  expulsion  of  uterine  contents.  The  signification  of  the  cervical  ganglion 
in  practice  is  evident  when  observed  that  trauma  or  shock  on  the  pelvic  brain 
will  kill  in  a  few  hours.  For  example,  I  performed  an  autopsy  on  the  body 
of  a  woman  after  her  first  child  who  had  ventral  hysteropexy  performed  on 
her  four  years  previously  and  in  whom,  immediately  subsequent  to  labor,  the 
uterus  invaginated,  killing  her  in  about  two  and  a  half  hours.  She  died 
from  shock,  which  went  swiftly  onward  and  swiftly  downward.     The  pelvic 


PHYSIOL*  )<;V 


149 


brain  dominates  the  rhythm  of  the  corpus  and  fundus  (uterus).  That  the 
uterus  is  supplied  by  sympathetic  nerves  and  cervix  by  spinal  is  significant  in 
practice.  For  example,  the  uterus  (corpus  and  fundus)  is  always  ready  for 
an  abortion,  because  it  is  always  in  rhythm.  The  cervix  is  never  ready  for 
an  abortion,  because  it  is  not  in  rhythm,  being  dominated  by  sacral  spinal 
nerve.  The  pelvic  brain  is  intimately  and  profoundly  connected  to  the 
abdominal  brain  by  a  direct  nerve  route  of  vast  nerve  plexuses  and  ganglia — 
viz.,  by  the  plexus  interiliacus  (hypogastricus)  and  plexus  aorticus.  Any 
disturbance  in  the  pelvic  brain  is  flashed  with  telegraphic  rapidity  to  the 
abdominal  brain,  and  most  of  the  consequent  pathologic  physiology  is  mani- 
fest from  the  stomach  by  disordered  rhythm  (vomiting  or  nausea),  absorption 
and  secretion. 


PELVIC  BRAIN 


Fig.  42.  Drawn  from  my  own  dissection.  Woman  about  thirty  years  of  age.  In  this 
subject  the  dissection  was  rather  deficient  than  excessive,  hence,  the  pelvic  brain  presents 
more  of  a  solid  ganglion  than  a  fenestrated  ganglion,  or  ganglionated  plexus.  1  and  2, 
pelvic  ganglion.  3,  rectum.  4,  uterus.  5,  bladder.  6  and  7,  sacral  ganglia.  8,  last  lumbar 
nerve.  9,  IV  sacral  nerve.  In  this  subject  the  pelvic  brain  results  from  the  union  of  the 
plexus  interiliacus  (1)  and  branches  from  II,  III  and  IV  sacral  nerves. 

The  detailed  dissection  was  not  continued  sufficiently  to  demonstrate  that  the  plexus 
interiliacus  emitted  separate  strands  directly  to  the  uterus  without  first  entering  the  pelvic 
brain.  In  this  subject  the  pelvic  brain  was  one  inch  in  length,  one-half  inch  in  width,  and 
one-fifth  inch  in  thickness.     Such  a  majestic  ganglion  must  be  endowed  with  giant  power. 


150  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

Age  Relations. — In  contra-distinction  to  the  abdominal  brain,  a  life-long 
functionating  organ,  the  pelvic  brain  possesses  age  relations  concomitant  with 
the  age  relations  of  the  tractus  genitalis.  The  age  relations  of  the  pelvic 
brain,  similar  to  those  of  the  tractus  genitalis,  depend  upon  the  volume  of 
blood  irrigating  it  at  the  different  phases  of  sexual  life,  as  pueritas,  pubertas, 
menstruation,  gestation,  puerperium,  climacterium,  senescence.  The  pelvic 
brain,  present  at  birth,  experiences  multiplication  of  its  ganglion  cells,  max- 
imum completion  and  minimum  atrophy  during  postnatal  life.  Its  function 
rises  and  falls  with  that  of  the  genitalis. 

I.  Pueritas. — In  childhood  the  pelvic  brain  is  present;  however,  the 
ganglion  cells  are  few  and  small.  The  cell  body  is  small,  slightly  granular. 
Cell  nucleus  is  distinct.  Cell  nucleolus,  small  and  indistinct.  The  ganglion 
cells  grow,  increase  gradually  with  the  years.  At  six  years  of  age  the  cell 
nucleus  is  marked  and  the  nucleolus  is  distinct. 

II.  Pubertas. — At  puberty  the  ganglion  cells  are  completely  developed 
(simulating  the  arteria  uterina). 

III.  Menstruation. — At  the  menstrual  period  the  hyperaemia,  congestion, 
may  aid  in  increasing  the  connective  tissue  cells. 

IV.  Gestation. — During  pregnancy  the  profound  and  continuous  hyper- 
aemia, the  permanent,  exalted  engorgement,  produces  an  increase,  a  multipli- 
cation of  interganglionic  cellular  nerve  and  connective  tissue,  which  force  the 
ganglion  cells  asunder.  This  lends  to  the  pelvic  brain  an  evident  increase  in 
its  gross  dimension  (not  positively  a  multiplication  cf  ganglion  cells).  The 
vast  majority  of  investigators  admit  that  the  pelvic  brain  hypertrophies  in 
its  nerve  and  connective  tissue  department  during  gestation  (not  in  ganglion 
cells).  However,  it  is  a  very  difficult  problem  to  solve,  as  we  are  not 
familiar  with  the  number  of  ganglion  cells  present  at  any  one  epoch  of  sexual 
life.  Besides,  inflammatory  processes  in  the  tractus  genitalis  modify  or 
destroy  the  ganglion  cells.  Also  individual  variations  confuse.  Connective 
tissue  develops  in  the  pelvic  brain  during  the  active  function  of  the  genitals, 
in  maximum  sexual  life  (menstruation  and  gestation).  S.  Pessimski,  in  his 
able  production  (1903),  asserts  that  the  character  of  the  plexus  (pelvic  brain) 
and  the  dimensions  of  the  ganglia  are  identically  the  same  in  gravid  and  non- 
gravid  subjects. 

V.  Puerperium. — In  the  devascularization  of  the  puerperal  stage  cel- 
lular elements  will  perhaps  degenerate,  atrophy,  disappear. 

VI.  Climacterium. — In  the  climacteric  stage  the  blood  supply  begins  to 
diminish,  increasing  the  interganglionic  cellular  elements,  which  forces  the 
ganglion  cells  asunder,  and  the  parenchyma  (ganglion  cells)  begins  its  final 
long  night  of  atrophy  and  disappearance. 

VII.  Senescenee. — In  senescence  the  arteria  uterina  loses  its  spirality, 
becoming  extended,  its  lumen  becomes  diminished,  its  walls  become  hyper- 
trophied  and  the  volume  of  blood  supplying  the  pelvic  brain  (and  genitals) 
gradually  decreases  with  consequent  atrophy.  The  interganglionic  connec- 
tive and  nerve  tissue  increases,  multiplies,  while  the  parenchyma  (ganglion 
cells)  becomes  atrophied,  compressed  to  death  by  cicatrization  and  lack  of 


PATHOLOGY  151 

blood.  By  progressive  interganglionic  nerve  and  connective  tissue  multipli- 
cation the  ganglion  cells  are  separated  and  compressed,  gradually  losing 
their  nucleolus,  and  later  their  nucleus,  and  finally  the  granulation  of  the 
ganglion  cell  body  disappears  and  the  ganglion  cells  become  reduced  to 
a  homogeneous  mass — atrophic  death.  They  have  ceased  to  command  the 
rhythmic  uterus.  The  senescent  decadent  process  of  the  pelvic  brain  is 
identical  with  that  of  the  tractus  genitalis  (/.  e.%  for  the  segment  supplied 
by  the  arteria  uterina). 

(O  Remarks  on  the  Pathology  of  the  Pelvic  Brain. 

The  pelvic  brain  is  subject  to  disease  similar  to  other  abdominal  viscera. 

Are  diseases  of  the  pelvic  brain  accompanied  by  a  range  of  recognizable 
symptoms?  In  some  700  personal  autopsic  inspections  of  the  abdominal 
viscera  I  observed  that  in  80  per  cent,  of  female  subjects  the  tractus  genitalis 
presented  disease — inflammation.  The  majority  of  these  inflammatory 
processes  are  practically  peritoneal  only,  and  would  hence  not  materially 
interfere  with  the  pelvic  brain  in  structure  or  function.  However,  there  are 
two  other  classes  of  subjects  in  which  peritoneal  inflammatory  processes 
traumatize  the  structure  and  compromise  the  function  of  the  pelvic  brain, 
viz. :  (a)  Peritonitis,  with  extensive  adhesions,  contracting  in  subjects  where 
the  peritoneal  adhesions  by  contraction  dislocate  the  viscera,  compromising 
the  circulation  (blood  and  lymph)  and  function  while  the  traumatism  of  the 
peritoneal  contractions  on  the  pelvic  brain  compromises  its  circulation, 
function,  structure  and  nourishment,  (b)  In  subjects  where  the  inflamma- 
tory process  penetrates  to  various  degrees  in  the  pelvic  subserosum  with 
resulting  round-cell  infiltration  and  subsequent  contraction  of  cellular  tissue. 
In  cellulitis  the  cicatricial  contraction  is  more  profound  on  the  pelvic  brain, 
with  consequently  more  profound  impression  in  compromising  its  circulation 
(blood  and  lymph)  and  traumatizing  its  ganglion  cells,  nerve  cords  and 
commissures  ending  in  degeneration.  Pelvic  peritoneal  adhesions  and 
pelvic  cellulitis  are  the  chief  diseases  which  attack  the  integrity  of  structure 
and  function  of  the  pelvic  brain.  The  advance  of  malignant  disease  in  the 
organs  adjacent  to  the  pelvic  brain  is  so  profound  in  its  traumatism  and 
compromisation  of  structure  and  function  that  practically  paresis,  paralysis 
or  death  of  its  structure  and  function  rapidly  ensues. 

W.  A.  Freund's  essay  on  parametritis  chronica  atrophicans  is  well 
known.  Inflammation  frequently  attacks  the  pelvic  brain,  and  the  resulting 
hypertrophy  and  atrophy  will  inevitably  damage  its  delicate  structure  and 
function.  No  abdominal  organs  present  more  palpable  macroscopic  devia- 
tion from  inflammatory  consequences  than  the  tractus  genitalis.  The 
inflammations  in  the  uterus  (myometritis)  and  ligamentum  latum,  with 
resulting  hypertrophy  and  atrophy,  are  common  observations.  These 
inflammatory  processes  are  accompanied  by  atrophy  and  compromisation  of 
blood  and  lymph  vessels.  Reflexes  of  various  kinds  and  degrees  follow  in 
the  inflamed  genitals— from  both  acute  and  chronic  states.  Cicatrization, 
sclerosis,   contracting   peritoneal    adhesions   in   the    pelvis   compromise   the 


15.2  THE  ABDOMINAL  AXD  PELVIC  BRAIX 

function  of  the  pelvic  brain  and  traumatize  its  structure.  The  observing 
gynaecologist  notes  far  more  reflexes,  hysteria,  neuroses  from  atrophic 
(genitals)  chronic  myometritis  than  from  hypertrophic  (genitals)  myo- 
metritis. The  rational  explanation  is  that  atrophic  states  in  the  uterus  and 
parauterine  peritoneal  and  cellular  tissue  (consequent  on  inflammation)  are 
accompanied  by  profound  compromisation  of  function  and  traumatization  of 
structure  in  the  pelvic  brain  and  its  adjacent  delicate  nerve  fibres.  As 
common  proof  one  can  cite  the  neurotic  hysterical  patient  with  atrophic 
pelvic  organs. 

The  pelvic  brain  will  present  anatomico-pathologic  reactions  from  toxic 
agents  similar  to  other  viscera-degeneration.  The  more  rapid  or  intense 
the  toxic  agent  the  more  profound  the  reaction.  The  toxic  infectious 
changes  in  the  pelvic  brain  may  be  parenchymatous  and  degenerative  in  the 
acute  forms,  nodular  in  the  less  acute  and  sclerotic  in  the  chronic  forms. 
The  toxic  infections  may  leave  sequels  in  the  pelvic  brain  as  in  other  viscera. 

Laignel  Lavastine  has  made  a  study  of  the  abdominal  sympathetic,  and 
has  attempted  to  demonstrate  that  some  of  the  neuroses  subsequent  to 
infectious  disease,  as  typhoid,  scarlet  fever,  diphtheria,  etc.,  may  be  due  to 
the  changes  effected  in  the  sympathetic  ganglia. 

Some  of  the  numerous  neuroses  accompanying  genital  disease  may  have 
an  anatomic  substratum  in  the  pelvic  brain.  We  have  noted  that  the 
rational  explanation  of  the  sudden  cessation  of  labor  for  a  time  is  doubtless 
due  to  trauma,  shock  on  the  plexus  interiliacus  or  pelvic  brain,  which  has 
become  paretic  by  the  impinging  of  the  harder  parts  of  the  child  on  the 
interiliac  plexus  as  it  journeys  through  the  pelvis.  Though  the  stately 
rhythm  and  measured  peristalsis  of  the  uterus  during  labor  presents  a 
wonderfully  established  phenomenon,  yet  by  trauma  of  the  child's  head 
on  the  pelvic  brain  it  is  quickly  deranged.  The  gynaecologist  may  claim 
that,  from  the  frequency  with  which  neuroses,  hysteria,  visceral  reflexes 
follow  pelvic  inflammations,  with  consequent  sclerosis  atrophy  in  the 
tractus  genitalis  (especially  myometritis  and  inflammations  of  the  ligamen- 
tum  latum),  the  neuroses  hysteria  reflexes  are  symptoms  of  diseases  in  the 
pelvic  brain. 

CONCLUSIONS    AS    REGARDS    THE    PELVIC    BRAIN. 

(A)  Anatomy. — The  pelvic  brain,  a  constant  structure,  is  practically 
formed  by  the  union  of  the  visceral  branches  (pelvic  splanchnics  II,  III  and 
IV)  of  the  sacral  plexus  with  the  interiliac  (hypogastric)  plexus.  It  is  a 
composite  or  compound  ganglion,  paired  and  practically  symmetrical  in 
dimension,  form,  position  and  weight.  The  pelvic  brain  is  located  bilat- 
erally at  the  cervico-vaginal  junction,  where  the  latter  is  in  contact  with  the 
rectum.  It  is  situated  extraperitoneally  in  the  parametrium  at  the  base  of 
the  ligamentum  latum,  on  a  level  with  internal  os  uteri  well  concealed  in 
connective  tissue.  Practically  the  position  of  the  pelvic  brain  is  at  the 
point  of  crossing  of  the  ureter  with  the  uterine  artery.  It  is  the  major 
assembling  center  for  the  pelvic  sympathetic.     It  is  surrounded  and  inter- 


:'\TII<)LOGY 


153 


woven  with  dense  subperitoneal  pelvic  connective  tissue,  presenting  difficul- 
ties of  exposition  by  dissection  on  account  of  its  simulation  to  adjacent 
tissue.  The  pelvic  brain  has  extensive  and  profound  connection  with  the 
uterus,  vagina,  ureter,  bladder  and  rectum.  The  composite,  compound 
ganglia  of  the  pelvic  brain  are  composed  of  multipolar  ganglionic  nerve  cells 
ensconced  in  periganglionic  tissue.     From  erect  attitude  the  pelvic  brain  has 


Fig.  43.  (A)  Drawn  from  the  pelvic  brain  of  a  girl  seventeen  years  of  age.  The 
ganglion  cells  are  completely  developed.  (B)  Drawn  from  the  pelvic  brain  of  a  three 
months'  normal  gestation.  The  gangl:on  cells  are  completely  developed.  Observe  the 
enormous  mass  of  connective  tissue  present.  (C)  Child  ll/2  years  old.  A  nerve  process 
courses  within  the  ganglion.  Few  and  small  ganglion  cells  incompletely  developed.  (D) 
Girl  ll/2  years  old.  A  nerve  process  branches  and  reunites  itself  with  the  intercellular  sub- 
stance. (E)  Girl  6  years  old.  The  ganglion  cells  are  presenting  development  (Redrawn 
after  Dr.  Sabura  Hashimoto.) 


changed  position,  moving  more  distalward  into  the  lesser  pelvis  and 
approaching  more  the  median  plane.  The  average  dimensions  of  the  adult 
pelvic  brain,  with  resting  uterus,  are:  Length  (proximadistal),  one  inch; 
width,  three-quarters  of  an  inch;  thickness,  one-sixth  of  an  inch.  In  the 
gestating  uterus  the  average  dimensions  of  the  pelvic  brain  are:     Length, 


154  THE  ABDOMINAL  AND  PELVIC  BRAIN 

one  and  one-half  inches;  width,  one  inch,  and  thickness,  one-fifth  of  an  inch. 
The  form  is  triangular,  quadrangular.  The  borders,  or  contour,  are  irregu- 
lar and  not  well  defined.  The  arrangement  of  the  pelvic  brain  consists  of 
(a)  afferent  or  centripetal  nerves  (entering  or  contributing  nerves)  from  the 
plexus  interiliacus  (sympathetic)  and  plexus  sacralis  (spinal);  (b)  efferent 
or  centrifugal  nerves  (distributing  or  visceral  nerves). 

The  afferent  nerves  enter  the  pelvic  brain  mainly  on  the  proximal  and 
external  borders  as  single,  slightly  plexiform  cords. 

The  efferent  nerves  radiate  mainly  from  the  median  and  distal  borders 
as  luxuriant  leashes  or  richly  ganglionated  plexuses. 

There  is  no  relation  in  number  or  dimension  between  the  afferent 
and  efferent  nerves.  The  pelvic  brain  is  a  fenestrated  ganglionic  mass.  Its 
consistence  is  moderately  dense  from  association  of  abundant  periganglionic 
tissue.  The  ganglia  of  the  pelvic  brain  vary  in  dimension,  location,  form, 
coalescence,  separat'on. 

To  expose  the  pelvic  brain  by  dissection  the  most  perfectly,  the  cadavers 
of  infants  preserved  in  alcohol  are  absolutely  necessary — superior  to  that  of 
adults. 

The  pelvic  brain  resembles  the  abdominal  brain  in  that  it  receives  the 
visceral  nerves  (pelvic  splanchnics)  from  the  II,  III,  IV,  sacral  nerves, 
while  the  abdominal  brain  receives  the  visceral  nerves  (abdominal  splanch- 
nics) from  the  VII  dorsal  to  the  II  lumbar  (thoracico-lumbar).  The  pelvic 
brain  is  accessible  to  palpation  per  vaginam  and  per  rectum. 

Practically,  the  genitals  are  supplied  from  two  sources,  viz. :  (a)  directly 
from  the  plexuses  of  the  pelvic  brain;  (b)  from  one  (to  several)  strands 
issuing  directly  from  the  plexus  interiliacus  (which  does  not  first  pass  through 
the  pelvic  brain). 

The  plexuses  of  the  pelvic  brain  (uterine,  ureteral,  vaginal,  vesical  and 
rectal)  anastomose,  connect,  solidly  and  compactly,  the  tractus  genitalis, 
part  of  the  tractus  urinarius  (ureter,  bladder),  part  of  the  tractus  intestinalis 
(rectum),  which  induces  them  to  act  clinically  as  a  joint  organ — injury  or 
disease  in  any  one  tract  produces  reflex  effects  in  the  other  two,  and  vice 
versa. 

{B)  Physiology. — The  function  of  the  pelvic  brain  is  practically  to  rule 
the  physiology  of  (a)  the  TRACTUS  GENITALIS;  (b)  part  of  the  tractus 
uriiiarius  (ureter,  bladder);  (c)  part  of  the  tractus  intestinalis  (rectum). 

The  physiology  of  the  tractus  genitalis  is  (a)  ovulation ;  (b)  secretion ; 
(c)  absorption;  (d)  peristalsis  (prenatal  and  common  with  functions  of  the 
abdominal  brain) ;  (e)  menstruation ;  (f)  gestation  (special  functions  of  the 
pelvic  brain),  and  (g)  sensation. 

The  pelvic  brain  is  a  nervous  center — i.e.,  it  receives,  reorganizes  and 
emits  nerve  forces.  The  pelvic  brain  is  a  local  nervous  executive  for  the 
common  functions  of  the  pelvic  viscera  (peristalsis,  absorption  and  secretion) 
and  for  the  special  function  of  the  tractus  genitalis  (ovulation,  menstruation 
and  gestation.)  The  pelvic  brain  was  originally  in  function  and  location  a 
vascular  brain — cerebrum  pelvicum  vasculare. 


I'ATIIOLOGY  155 

The  dynamics  of  the  pelvic  brain  include  the  initiation,  maintenance 
and  conclusion  of  parturient  peristalsis  (labor). 

The  ganglion  cervicale  assumes  the  dignity  of  a  brain  from  its  power  of 
reception,  reorganization  and  emission  of  nerve  impulses. 

Parturient  peristalsis  (labor)  is  initiated  by  the  distalward  movement  of 
the  child  and  the  consequent  mechanical  irritation,  pressure,  excitement  on 
the  pelvic  brain.  The  greater  the  distalward  movement  of  the  child  in  the 
pelvis  the  more  mechanical  irritation  from  the  fcetal  head  occurs  on  the 
pelvic  brain,  and  consequently  the  greater  number  of  nerve  elements 
(ganglia)  are  excited. 

The  pelvic  brain  functionates  as  a  unit,  possessing  no  segmental  gan- 
glionic differentiation  as  in  the  cranial  brain.  It  is  a  source  of  new  nerves,  a 
creating  center,  as  it  possesses  more  efferent  than  afferent  nerves.  The 
pelvic  brain  is  subordinate  to  the  abdominal  brain  in  total  number  of  gan- 
glion cells — not  in  specific  functions  (as  ovulation,  menstruation,  gestation). 
It  demedullates  nerves — i.e.,  medullated  nerves  enter  (afferent)  sheathed  and 
depart  (efferent)  demedullated,  unsheathed.  The  pelvic  brain  is  a  giant 
vasomotor  center  for  the  pelvic  viscera,  especially  for  the  tractus  genitalis. 
It  shares  in  the  execution  of  the  six  functions  of  the  genital  tract — viz.,  ovula- 
tion, secretion,  absorption,  peristalsis,  menstruation,  gestation.  The  pelvic 
brain  is  the  major  pelvic  reflex  center.  It  is  the  minor  abdominal  reflex 
center,  the  abdominal  brain  being  the  major  reflex  center.  It  possesses 
nutritive  power  over  its  peripheral  nerves.  The  pelvic  brain  arrives  at  its 
adult  maximum  dimensions  and  functionating  power  after  a  complete  gesta- 
tion. The  pelvic  brain  is  an  intermediary  agent  to  receive  and  modify  the 
spinal  and  sympathetic  nerve  forces  for  utilization  in  the  tractus  genitalis. 

The  pelvic  brain  experiences  an  age  relation  concomitant  with  that  of 
the  tractus  genitalis — i.e.,  with  the  utero-ovarian  artery.  The  age  relations 
of  the  pelvic  brain  depend  on  the  volume  of  blood  irrigating  it  at  different 
phases  of  sexual  life. 

(a)  In  pueritas  the  ganglion  cells  are  few  and  small. 

(b)  In  pubertas  the  ganglion  cells  are  completely  developed. 

(c)  In  menstruation  the  hyperemia,  congestion,  increases  the  connective 
tissue. 

(d)  In  gestation  the  profound  and  constant  hyperemia,  exalted  engorge- 
ment, produces  a  multiplication  of  ganglion  cells  and  an  increase  of  connec- 
tive tissue. 

(e)  In  puerperium  the  devascularization  of  the  ganglionic  cell  elements 
may  produce  degeneration,  atrophy. 

(f)  In  climacterium  the  blood  supply  decreases,  the  ganglionic  cells 
atrophy  and  the  connective  tissue  increases. 

(g)  In  senescence  the  ganglion  cells  atrophy  and  disappear,  while  the 
connective  tissue  multiplies,  increases.  The  pelvic  brain  begins  its  long 
night  of  atrophic  death. 

(O  Pathology. — The  pelvic  brain  is  subject  to  disease  similar  to  other 
abdominal  viscera.     As  the  tractus  genitalis  is  frequently  subject  to  infection 


156  THE  ABDOMINAL  AND  PELVIC  BRAIX 

and,  consequently,  inflammatory  processes  during  its  maximum  activity,  the 
pelvic  brain,  no  doubt,  becomes  diseased  and  manifests  symptoms.  Periton- 
itis, cellulitis  and  infectious  processes  will  affect  the  pelvic  brain  and  induce  a 
series  of  neurotic  symptoms.  Atrophic  genitals  following  inflammatory 
processes  are  frequently  accompanied  by  neuroses.  The  most  typical  disease 
is  that  known  from  W.  A.  Freund  as 

Parametritis  Chronica  Atrophicans.— The  anatomic  substratum  of  reflex 
neuroses,  hysteria,  may  be  found  in  disease  of  the  pelvic  brain;  cicatricial 
contraction  traumatizes  the  pelvic  brain.  The  pelvic  brain  may  be  the  agent 
of  valuable  therapeutics— e.g.,  in  post-partum  haemorrhage  massage  of  the 
pelvic  brain  may  be  accomplished  per  rectum,  per  vaginam,  manipulation 
of  the  uterus  or  light  stroking  of  the  plexus  interiliacus  inducing  the  elastic 
and  muscular  bundles  of  the  myometrium  to  contract  like  living  ligatures, 
controlling  vessel  lumen. 

BIBLIOGRAPHY  OF  THE  PELVIC  BRAIN    (GANGLION  CERVICALe). 

Eustachius,  B.  (died  1574).     Tabulae  Anatomicae,  Amsterdam,  1722. 

de  Graaf,  Regner  (1641-1673).     Opera  omnia,  Amsterdam,  1705. 

Willis,  Thomas  (1622-1675).  Cerebri  nervorumque  descriptio,  Geneva, 
1680. 

Haller,  Albertus  (1708-1777).     Elementa  physiologiae.     Laus,  1778. 

Vieussens,  R.  (1641-1716). 

Walter,  J.  G.  (1734-1818).  Tabulae  nerv.  thoracis  et  abdominis.  Ber- 
olini,  1783. 

Hunter,  William  (1718-1783).  Anatomic  description  of  the  pregnant 
uterus.     1802. 

Osiander,  F.  B.  (father)  (1757-1822).  Handbuch  der  Entbindungskunst, 
1818. 

Osiander,  J.  F.  (son)  (1787-1855).  Literario  a  mediocrum  ordine  praemio 
Commentatio-physiologica  quae  disserata  uterum  nervos  habere  in  certamine. 
Literario  a  mediocrum  ordine  praemiornat.     Goettingen,  1808. 

Bourgery.  J.  M.  (1797-1845),  1840,  and  Claude  Bernard  (1813-1778),  1840. 

Tiedemann,  Friedricus  (1781-1861).  Tabulae  nervorum  uteri.  Heidel- 
berg, 1822. 

Lobstein,  J.  G.  C.  F.  (1777-1815).  De  nervi  sympathici  humani  fabrica, 
etc.     Paribsii,  1823. 

Kilian,    F.     (1800-1864).  Die    Nerven    des     Uterus.        Zeitschrift    f 

rationelle  Med.  1851.  Burns'  Handbuch  der  Geburtshuelfe,  herausgegeben 
von  Kilian.     Bonn,  1834. 

Boivin.  Handbuch  der  Geburtshuelfe,  uebersetzt  von  Robert  Kassel. 
1829. 

Lee,  Robert  (1798-1878).  Philosophical  transactions.  1842.  Also  the 
anatomy  of  the  nerves  of  the  uterus.     1841. 

Beck,  Thomas  Snow  (1814-1847).     Philosophical  transactions,  1846. 

Clay.     Nerves  of  the  uterus.     1845. 

Swan.     The  physiology  of  the  nerves  of  the  uterus.     1846. 


PELVIC  BRAIN  OF  ADULT 

Fig.  44.  B  represents  the  pelvic  brain.  The  plexus  aorticus  extends  from  the  abdominal 
brain  to  the  aortic  bifurcation  or  interiliac  disc  (H).  The  plexus  interiliacus  (hypogastri- 
cus)  extends  from  the  interiliac  disc  (H)  to  the  pelvic  brain  (B).  It  is  evident  that  the 
pelvic  brain  is  the  result  of  the  coalescence  of  the  plexus  interiliacus  and  sacral  nerves  II, 
III  and  IV.  Note  that  part  of  the  plexus  interiliacus  sends  nerve  cords  directly  to  the 
uterus.  16a  and  16  is  the  arterio-ureteral  crossing.  The  ureters  were  dilated.  Note  the 
great  vesical  nerve  extending  from  III  to  X.  In  this  drawing  suggestions  from  Franken- 
hauser  were  employed. 


158  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

Jobert  de  Lamballe  (1779-1867  .  Comptes  des  science  de  L'Academie, 
T.  XII..  Xo.  20,  Mai  17.  Recherches  sur  la  disposition  des  nerfs  de  l'uterus, 
etc. 

Langenbeck's  Atlas.     Tafel  11  and  12.     Fasc.  iii.  Neurologic 

Louget.     Anatomie  und  Physiologie  des  Xerven-System.     Bonn,  1819. 

Hirschfeld  and  Laville.  Neurologie  descript.  et  iconographie  du 
systeme  nerveux.     Paris,  1853. 

Frankenhauser,  Ferdinand  (died  1894).  Die  Nerven  de  Gebaermutter. 
Jena,  1867. 

Koerner,  Thomas.     De  nervi  uteri.     1865. 

Polle.     Preisschrift  (Thesis).     Goettingen,  1875. 

Koch,  Robert.     Ganglia  of  the  uterus.     1^65. 

Keilman,  Alexander,  Dorpat.  Zeitschrift  f.  Geb.  und  Gyn.  Bd.  22. 
Ursache  des  Geburtseintritts.     1881. 

Goltz.     Pflueger's  Arch.     Bd.  9. 

Rohrig.  Virch.     Arch.  Bd.  76.     1679. 

Jostreboff.  These  St.  Petersburg,  1881.  Anatomie  normal  et  patho- 
logique  du  ganglion  cervicale  de  l'uterus. 

Freund.  W.  H.  Verh.  der  Xat.  Vers.     Strassburg,  1885. 

Cohnstein.     Arch.  f.  Gyn.     Bd.  18.     1881. 

Historical  study  of  the  methods  of  experiments  to  determine  the  nerves 
of  the  uterus. 

Robinson,  Byron.  1894  to  1899.  A  series  of  articles  on  the  sympathetic 
nervous  system  (abdominal  and  pelvic  brain)  published  in  a  number  of 
journals.  Book  on  "Abdominal  Brain  and  Automatic  Visceral  Ganglia," 
published  in  1^99. 

Mayer.  R.     Virch.  Arch.  Bd.  85. 

Franz.     Centralblatt  f. Gynecol.,  Xo.  "24.     1904. 

Freund,  W.  A.     Festschrift  fur  Chrobak.     1903. 

von  Herff,  Munchen.     Medicin.     Wochensch.,  Xo.  4.     1^92. 

Gawronsky.     Arch.  f.  Gyn.  Bd.  47.     1^94.     Nerve  endings  in  the  uterus. 

Knupffer.  Wegen  der  Ursache  des  Geburtseintritts.  Inaugural  desser- 
tation.     Dorpat,  1892. 

"Waldeyer,  Wm.     Das  Becken.     Bonn,  1^99. 

Pissemski,  S.  Monatsschrift  f.  Gehurtshulfe  und  Gynakologie,  Bd.  17. 
1903.  Zur  Anatomie  des  Plexus  fundamentalis  uteri  beim  Weibe  und 
gewissen  Thieren. 

Ph.  Jung.  Untersuchung  ueber  die  Innervation  der  weiblichen  Genital- 
Organe.  Monatsschrift  fiir  Geburtshiilfe  und  Gynakologie,  Bd.  21.  Heft  I, 
Jan..  1905. 

Hashimoto,  Sabura.  Beitrage  zur  Geburt  und  Gynakol.  Bd.  8.  Heft 
I,  1894.     (Anatomy  and  histology  of  the  cervical  ganglion). 

Freund.  W.  A.     Verhand.  d.  76.     Xat.  Vers.     Breslau,  1904. 


CHAPTER  XIV. 

GENERAL  CONSIDERATIONS. 

Every  thoracic  and  abdominal  organ  has  its  own  rhythm  (peristalsis). 
A  little  knowledge  is  a  dangerous  thing. — Lord  Bacon. 

The  original  investigations  of  the  sympathetic  nervous  system,  in  both 
humans  and  animals,  upon  which  this  work  is  founded,  were  begun  in  1887, 
and  have  been  carried  on  quite  steadily  since.  The  works  of  Fox,  Chapin, 
Gaskell,  Eulenberg  and  Guttmann,  Patterson,  Robert  Lee,  Lobstein,  Snow- 
Beck,  Rauber  and  Frankenhauser  have  been  carefully  studied.  A  number  of 
physiologies,  as  well  as  some  fifty  anatomies,  were  searched.  One  hundred 
human  cadavers  have  been  dissected  with  reference  to  the  sympathetic 
system  and  also  among  the  lower  animals,  those  of  the  rodents  and  solipeds — 
cow,  calf,  pig,  dog,  fish,  bird,  frog,  rabbit,  rat  and  sheep.  The  dissections 
have  comprised  in  addition  a  considerable  number  of  embryos,  human  and 
animal.  The  results  of  this  work  demonstrate  that  the  ganglia  of  the  sym- 
pathetic nerve  are  much  larger  in  the  lower  animals  than  in  man.  That  is, 
as  the  scale  of  animal  life  ascends,  the  sympathetic  system  proportionately 
decreases,  while  the  cerebro-spinal  system  proportionately  enlarges.  In  short 
the  higher  the  life  the  more  dominant  the  cerebro-spinal  system, 'and  the  lower 
the  life  the  more  dominant  the  sympathetic  system. 

In  mammals  there  exist  two  brains  of  almost  equal  importance  to  the 
individual  and  also  to  the  race:  One  is  the  cranial  brain,  the  instrument  of 
mental  progress  and  physical  protection ;  the  other  is  the  abdominal  brain, 
the  instrument  of  nutrition  and  visceral  rhythm.  To  the  casual  observer 
the  cranial  cerebrum  seems  to  overshadow  all  other  nervous  centers.  The 
anterior  brain  of  mammals,  situated  in  the  skull,  is  so  manifest  to  the 
practitioner  that  it  seems  to  do  all  the  business  of  the  nervous  system.  It 
is  true  that  the  knot  of  life  is  situated  at  the  base  of  the  cranial  brain,  and 
by  one  prick  of  a  bodkin  in  the  medulla,  life  may  be  quickly  extinguished. 
Yet  a  derangement  of  the  abdominal  brain  destroys  life  as  effectually, 
though  not  so  quickly.  A  study  of  the  abdominal  brain  brings  to  light 
views  which  are  both  important  and  practical.  In  the  cranial  brain  resides 
the  consciousness  of  right  and  wrong.  Here  is  the  seat  of  all  progress 
mental  or  moral,  and  in  it  lies  the  instinct  to  protect  life  and  the  fear  ot 
death.  But  in  the  abdomen  there  exists  a  brain  of  wonderful  powers.  It 
presides  over  organic  life.  Its  great  functions  are  two — nutrition  and 
visceral  rhythm.  In  this  abdominal  brain  are  repeated  all  the  physiological 
and  pathological  manifestations  of  nutrition  and  rhythm  of  viscera.  It 
controls  nourishment  and  secretion.  It  initiates,  sustains  and  prohibits 
rhythm.      It  receives  sensations  and  transmits  motion.      It  is  an  automatic 

169 


100  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

nervous  center.  It  is  a  physiological  and  anatomical  brain.  In  short,  it  is 
a  nervous  ganglion;  only  a  ganglion  possesses  rhythmical  power. 

The  abdominal  brain  is  situated  around  the  root  of  the  celiac  axis  and 
superior  mesenteric  artery.  It  lies  just  behind  the  stomach,  consists  of  a 
blended  meshvvork  of  nervous  ganglia,  and  is  made  up  of  the  union  of  the 
splanchnics,  the  two  pneumogastrics  and  the  right  phrenic. 

There  is  a  difference  between  the  right  and  left  abdominal  brain.  The 
left  is  more  closely  packed  together;  it  is  retort-shaped,  chiefly  consists  of  a 
large,  solid  ganglion  and  is  apparently  an  expansion  of  the  lower  end  of  the 
left  splanchnic  nerve  and  is  larger  than  the  right.  The  right  half  of  the 
abdominal  brain  is  more  of  a  meshwork  than  the  left ;  it  is  perforated  with 
numerous  apertures,  in  short,  is  flatter  and  wider  than  its  fellow.  I  am 
convinced  that  its  flatness  is  due  to  the  pressure  of  the  inferior  vena  cava. 

The  abdominal  brain  really  consists  of  two  ganglia.  These  two  ganglia 
are  sometimes  called  semilunar,  but  I  never  saw  one  of  such  shape.  The 
two  ganglia  are  united  by  cords  at  the  foot  of  the  celiac  axis  and  are  known 
as  the  solar  or  epigastric  plexus.  This  abdominal  brain  lying  along  the 
aorta  just  behind  the  stomach  is  a  silent  power  in  assimilation  and  rhythmical 
movements,  unless  some  organ  is  deranged.  Observations  of  the  disturbance 
of  visceral  functions  in  women  who  were  the  subjects  of  pelvic  disease  led 
me  to  follow  the  work. 

Disease  of  the  viscera  is  likely  to  disturb  the  two  great  functions  of  the 
abdominal  brain:  nutrition  and  rhythm.  The  abdominal  brain  distributes  its 
branches  to  all  the  vascular  system — artery,  vein  and  lymphatic.  The 
branches  of  nerves  will  sometimes  surround  the  artery  like  a  sheath  or  pass 
along  its  parallel  strands.  In  short,  the  branches  of  the  sympathetic  nerves 
are  carried  to  all  parts  of  the  economy  on  the  walls  of  the  blood-vessels. 
The  caliber  of  the  blood-vessels,  especially  the  smaller  ones,  is  controlled 
by  these  fine  strands  of  nerves.  They  may  produce  by  their'action  the  scarlet 
flush  (capillary  dilatation)  of  the  cheek,  or  the  marble  paleness  (capillary 
contraction)  of  fright.  Several  years  ago,  from  experiments  on  the  pregnant 
uterus  of  slaughtered  cows,  I  became  thoroughly  convinced  that  the  sympa- 
thetic nerve  is  the  cause  of  rhythm,  while  the  cerebro-spinal  nerves  prohibit 
rhythm.  It  is  evident  that  the  rhythmical  waves  in  the  fundus  and  body  of 
the  uterus  are  entirely  due  to  the  sympathetic,  which  almost  alone  supplies 
it.  The  sober  stillness  and  non-rhythmical  motion  of  the  uterine  neck  is 
due  to  the  excessive  supply  of  spinal  nerves.  The  order  from  the  cranial 
brain  for  motion  is  active,  direct  and  reflex,  subsiding  after  action.  But 
the  order  from  the  abdominal  brain  is  rhythmical,  and  the  rhythmical 
movements  play  on  all  vessels  and  hollow  organs,  on  the  circulatory  appa- 
ratus and  the  viscera. 

The  abdominal  brain  presides  likewise  over  the  glandular  system.  Here 
it  holds  the  balance  of  power  between  normal  blood-tissues  and  substances  to 
be  excreted.  The  abdominal  brain  controls  secretion.  The  orders  which  it 
sends  out  to  each  gland,  however,  must  be  reorganized  in  each  separate 
viscus,  i.  c,  in   the  periphery  of  the  nerves.     The  orders  to  the   liver  are 


GENERAL   CONSIDERATIONS  161 

manifest  in  the  products  of  bile,  glycogen  and  urea.  The  forces  sent  to 
the  digestive  tract  from  the  abdominal  brain  are  obvious  from  the  secretion  of 
the  digestive  fluids,  from  the  mouth  to  the  rectum.  The  sympathetic  system 
holds  the  glandular  system  as  a  unit,  e.  g.,  when  the  ovarian  gland  is  injured 
or  removed,  inflammation  may  arise  in  the  parotid  gland.  And  mumps  and 
parotitis  may  be  accompanied  by  orchitis.  The  rhythm  of  glands,  such  as 
the  liver  and  spleen,  is  possible  from  their  elastic  capsules.  The  orders 
from  the  abdominal  brain  to  the  digestive  glands  may  become  so  violent  that 
Auerbach's  plexus  throws  the  muscle  of  the  intestine  into  rigid  contraction, 
and  Meissner's  plexus  may  secrete  so  rapidly  that  an  active  diarrhea  may 
arise  in  a  few  minutes.  It  has  been  observed  that  herds  of  cattle  on  a  ship 
have  been  attacked  with  diarrhea  five  minutes  after  the  boat  was  put  in 
motion.  The  abdominal  brain  was  suddenly  disturbed.  The  sweat-glands 
may  be  irritated  so  violently  that  the  entire  body  becomes  suddenly  bathed 
in  perspiration.  Much  execution  may  be  done  by  inhibiting  the  sweat- 
centers. 

Excessive  or  deficient  gland  secretion,  then,  depends  on  the  abdominal 
brain  and  its  principal  machines.  The  gynecologist  sees  wonderful  rhyth- 
mical movement  in  the  generative  apparatus,  and  he  must  refe^this  to  the 
orders  of  the  abdominal  brain.  The  oviducts  and  ovaries  pass  through 
rhythmical  circles  due  to  nervous  bulbs  situated  in  their  walls.  I  named  and 
wrote  of  these  as  "automatic  menstrual  ganglia,"  several  years  ago.  The 
ganglia  of  the  oviduct  and  uterus  which  cause  the  monthly  rhythm  are 
entitled  to  due  respect,  as  well  as  the  peripheral  digestive  and  cardiac  ganglia. 
Again,  there  is  a  mechanism  called  the  vasomotor  center,  which  distributes 
itself  in  the  medulla  and  along  the  spinal  cord.  If  the  abdominal  brain  is 
disturbed  the  vasomotor  center  becomes  deranged  and  the  skin  will  be  waxy 
pale  or  scarlet  red.  Under  this  category  come  the  cold,  white  hands  and 
feet  of  women,  and  the  flushes  and  flashes  at  the  menopause.  In  some 
patients  I  have  seen  the  neck  and  face  show  variations  of  color  like  that  in  a 
revolving  electric  light.  The  wave  of  redness  will  gradually  pass  over  one 
side  of  the  face  and  neck,  and  as  it  slowly  disappears  (two  to  four  minutes), 
the  paleness  which  follows  is  of  a  marble  whiteness.  Then  the  other  side  of 
the  face  shows  that  its  capillaries  go  through  a  slow  rhythm  of  dilatation  and 
contraction.  In  ten  minutes  all  the  rhythm  is  over  and  the  nervous,  pale 
face  again  appears. 

Uterine  hemorrhage  from  a  myoma  is  reflex  and  accomplished  by  the 
sympathetic  system.  The  bleeding  is  due  to  loss  of  tone  in  the  vessels  of 
the  endometrium.  The  irritation  starts  in  the  mucous  membrane  of  the 
uterus  and  passes  up  to  the  abdominal  brain,  where  the  force  is  reorganized 
and  sent  to  the  vasomotor  centers  of  the  medulla  and  cord.  Now,  a  con- 
tinuous irritation  soon  disarranges  a  center  and  the  vasomotors  sooner  or 
later  lose  the  power  to  control  the  blood  .vessels  of  the  endometrium  and 
become  deficient  in  tone.  It  may  be  frequently  observed  that  in  a  myoma- 
tous condition  the  tone  of  the  vessels  in  the  endometrium  is  restored  and  the 
bleeding   ceases   for  a  time,  only   to  be   renewed   on   exhausting   irritation. 


162 


THE  ABDOMIXAL  AXD  PELVIC  BRAIX 


CARDIAC  NERVES 


Fig.  45  represents  the  vaso-motor  nerves  supplying  the  heart.  The  heart  is  the  typical 
organ  of  popular  demonstration  of  rhythm  or  peristalsis  in  the  body.  It  is  enormously 
supplied  with  nervus  vaso-motorius  besides  by  the  ganglia  of  Bidder,  Schmidt,  Remak, 
Ludwig,  Wrisburg,  all  but  one  located  in  the  cardise  parietes. 


GENERAL   CONSIDERATIONS  163 

Hence,  we  consider  hemorrhage  from  a  myomatous  uterus  as  reflex.  It  con- 
sists in  irritation  followed,  through  reflex  action,  by  vasomotor  paralysis, 
which  harbors  congestion.  We  note,  then,  that  the  abdominal  brain  presides 
over  significant  organs  in  man.  It  controls  the  forces  which  hold  man's 
body  intact.  It  has  a  very  subtle  way  of  enforcing  chemistry  to  subserve  its 
ends. 

A  general  summary  of  the  abdominal  brain  is  that  (a)  it  presides  over 
nutrition;  (b)  it  controls  circulation;  (c)  it  controls  gland  secretion;  (d)  it 
presides  over  the  organs  of  generation  ;  (e)  it  influences  in  a  dominant,  though 
not  an  absolute,  control  its  peripheral  visceral  automatic  ganglia. 

Each  of  the  above  will  again  be  discussed. 

The  ideal  nervous  system  is:  (1)  a  ganglion  cell;  (2)  a  conducting  cord; 
(3)  a  periphery.  The  sympathetic  nervous  system  possesses  all  three  in  an 
eminent  degree.  The  abdominal  brain  represents  the  central  ganglion  cell. 
Its  thousands  of  distributing  and  communicating  fibers  represent  the  conduct- 
ing cord.  The  various  ganglionic  machines  located  in  each  viscus  represent 
the  periphery. 

In  regard  to  the  independence  of  the  sympathetic  nerve  we  wish  to  say 
that  it  is  not  entirely  independent  in  action,  but  it  maybe  insisted  that  it  has 
certain  amount  of  independence  which  is  very  manifest  in  rhythmical 
motion.  The  dependence  and  independence  of  the  (a)  cerebro-spinal  axis; 
(b)  the  abdominal  brain  and  (c)  the  automatic  visceral  ganglia  may  be 
illustrated  by  (1)  the  federal  government;  (2)  the  state  government  and  (3) 
the  city  or  county  government. 

The  cerebro-spinal  axis  typifies  the  federal  government,  and  is  endowed 
with  the  chief  rule  of  the  animal.  It  is  the  central  power  and  all  others  must 
submit  to  it.  It  is,  moreover,  to  a  large  extent,  under  the  will  as  far  as 
motion  is  concerned. 

The  abdominal  brain  is  the  state  government.  In  fact,  it  exercises  many 
functions  almost  entirely  independent.  The  abdominal  brain  sends  its 
physiologic  orders  to  all  the  visceral  ganglia.  If  healthy,  all  obey,  but  dis- 
turbing pathologic  changes  cause  some  to  stop,  or  act  irregularly. 

The  automatic  visceral  ganglia  situated  in  each  organ  represent  the  county 
or  city  government.  The  city,  or  count)',  government,  is  free  from  neither 
state  nor  federal  government,  but  still  it  has  normal  independence  which  it 
freely  exercises.  The  same  views  may  be  illustrated  by  society  and  labor  in 
general  where  division  of  labor  exists,  and  where  certain  sections  exercise 
almost  independent  rights.  Thus  the  sympathetic  nervous  system  may  be 
considered  to  be  independent  to  a  certain  degree. 

After  a  large  number  of  dissections  on  man  and  animals  I  find  that  the 
ganglionic  system  of  the  female  is  larger  and  more  marked  than  that  of  the 
male.  Females  seem  to  have  more  distinct  ganglia  and  more  marked  con- 
ducting cords.  I  have  not  investigated  the  peripheral  nerve  supply  suffici- 
ently, so  far,  to  render  any  opinion.  I  have  found  the  abdominal  brain  and 
ganglia  relatively  larger  in  animals  than  in  man.  The  abdominal  brain  is 
very  large  in  the  dog,  in  proportion  to  his  cranial    brain.       Man's   cranial 


164  THE  ABDOMINAL  AND  PELVIC  BRAIN 

brain  Las  grown  relatively  faster  than  his  abdominal  brain,  and  I  think  man 
suffers  more  from  malnutrition  than  do  the  animals,  so  that  he  pays  dearly 
for  his  superior  cranial  brain  power.  Besides,  it  appears  that  man's 
abdominal  brain  (and  superior  cervical  ganglion)  is  very  liable  to  deteriorate 
with  age.  Disease  is  very  apt  to  arise  in  the  above  ganglia  after  forty  years 
of  age.  Perhaps  no  animal  suffers  so  much  from  indigestion  as  man  and  so 
far  as  I  know  he  has  not  only  the  smallest  abdominal  brain,  but  it  is  attacked 
the  most  severely  with  disease.  The  latest  researches  seem  to  show  that  the 
sympathetic  nervous  system  originates  by  sprouting  from  the  ganglia  on  the 
posterior  roots  of  the  spinal  nerves.  Some  believe  that  the  sympathetic 
nerve  originated  from  the  adrenal.  Some  points  relative  to  the  sympathetic 
nerve  and  the  suprarenal  capsules  are  quite  obscure. 

The  distribution  of  the  sympathetic  nerve  is  peculiar.  It  consists  of 
three  great  parts: 

1.  There  exists  a  double  lateral  chain  of  ganglia  lying  on  each  side  of 
the  vertebral  column  and  extending  from  the  skull  to  the  coccyx.  The 
ganglia  correspond  generally  in  number  to  the  vertebras,  except  in  the  neck, 
where  the  seven  are  blended  into  three.  The  ganglia,  no  doubt,  represent 
the  original  segmentation  of  the  body.  Now,  the  lateral  chain  of  sympa- 
thetic ganglia  is  connected  with  the  cranial  nerves,  and  with  the  spinal 
nerves.  It  is  strongly  connected  with  the  cranial  nerves,  and  also  very 
intimately  connected  to  each  side  of  the  vertebral  columns,  out  of  the  way 
of  pressure.  A  notable  feature  in  regard  to  the  lateral  chain  of  the  sympa- 
thetic is  that  it  is  very  intimately  connected  with  the  cranial  nerves,  and 
also  very  intimately  connected  with  the  sacral  nerves.  In  other  words,  it 
blends  at  the  ends  very  closely  with  spinal  and  cranial  nerves,  but  is  less 
intimately  associated  in  the  middle  with  the  spinal  nerves.  The  best  way  to 
demonstrate  the  sympathetic  system  in  the  human  is  to  place  an  embryo  or 
fetus  in  alcohol  and  then  open  the  thoracic  and  abdominal  cavities,  when 
the  chain  can  be  easily  observed  through  the  pleura  and  peritoneum.  The 
sympathetic  nervous  system  is  relatively  much  larger  in  the  fetus  than  in 
the  adult.  In  a  dog  just  killed  one  can  see  the  sympathetic  nerves  through 
the  pleura  very  easily  and  they  can  be  observed  also  through  the  peritoneum. 

2.  The  second  part  of  the  sympathetic  consists  of  four  great  plexuses 
of  nerves,  situated  anterior  to  the  vertebras,  called  prevertebral  plexuses. 
One  of  the  pharyngeal,  situated  around  the  larynx.  Another  is  the  cardiac 
and  pulmonary  plexus.  A  third  is  the  solar  or  epigastric  plexus,  situated 
around  the  coeliac  axis  and  superior  mesenteric  artery.  The  ganglia  in  the 
solar  plexus  are  what  I  am  calling  the  abdominal  brain.  A  fourth  plexus  lies 
in  the  pelvis,  and  is  distributed  to  the  generative  and  urinary  organs  and 
rectum. 

3.  The  third  part  of  the  sympathetic  consists  of  the  peculiar  mechanism 
at  the  ends  of  the  nerves  situated  in  each  viscus.  It  is  termed  the  peripheral 
apparatus.  In  a  diagnostic  sense  the  peripheral  apparatus  is  the  most 
important  to  the  physician,  as  he  can  often  only  make  his  diagnosis  by  the 
manifestation  of  the  disturbances  of  the  periphery  of  a  nerve  in  a  viscus: 


GENERAL   CONSIDERATIONS  165 

c.  g.,  in  dyspepsia,  Auerbach's  and  Meissner's  plexus  may  be  wrong;  in 
jaundice  the  automatic  hepatic  plexus  may  be  wrong,  and  bile,  glycogen  and 
urea  fail  in  proper  quantity.  It  is  well  to  remember  that  there  are  three 
more  or  less  distinct  splanchnics  distributed  in  the  viscera. 

TIic-  splanchnics  are  the  inhibitory  nerves  of  the  viscera,  e.g.,  of  sensa- 
tion, motion  and  vasomotor  action.     We  note  the  following  distribution: 

1.  There  are  the  cervical  splanchnics,  which  arise  in  the  cord  from  the 
first  cervical  to  the  fourth  dorsal.  These  splanchnic  nerves  mainly  reach  the 
viscera  (heart,  stomach,  etc.)  by  traveling  up  the  cervical  portion  of  the 
spinal  accessory  and  then  passing  down  the  vagus  (especially  the  right). 

2.  The  second  splanchnics  arise  in  the  cord  from  the  second  dorsal  to 
the  second  lumbar  and  pass  through  the  rami  communicantes  to  the  three  or 
four  abdominal  splanchnics,  whence  they  pass  to  the  abdominal  brain. 
These  govern  the  vascular  area  of  the  intestines,  etc. 

3.  There  is  also  a  third  set  of  these  nerves,  called  the  pelvic  splanch- 
nics. They  pass  from  the  cord  by  way  of  the  second  and  third  sacral  nerves 
and  do  not  enter  the  lateral  chain,  but  pass  to  the  hypogastric  and  thus 
supply  the  genitals. 

From  the  origin  of  these  three  great  splanchnics  (cervical,  abdominal 
and  pelvic),  it  is  clear  why  irritation  or  a  blister  on  the  lower  part  of  the 
back  of  the  neck  is  so  effective  in  dispelling  visceral  disturbances  The 
blister  inhibits  the  vasomotor  centers  and  thus  soon  rights  the  vascular 
disturbances  in  the  viscera. 

The  three  splanchnics  control  the  vasomotor  region  of  the  viscera.  It 
may  be  considered  that  the  sympathetic  nerve  is  endowed  with  sensation  and 
motion.  But  the  sensation  is  dull  in  the  sympathetic,  and  its  motion  is 
rhythmical.  But  the  utility  of  the  sympathetic  in  the  animal  economy  is  not 
fully  settled.  The  reason  is,  that  experiments  on  this  nerve  are  not  per- 
fectly decisive,  and  also  because  it  is  so  intimately  blended  with  the  cerebro- 
spinal nerves.  But  some  study  has  convinced  me  that  it  plays  a  large  role 
in  chronic  or  remote  uterine  disease,  and  that  is  what  has  called  out  this 
paper.  The  sympathetic  nerve  produces  involuntary  movements.  It  is 
called  the  ganglionic  nerve,  from  the  tendency  to  the  formation  of  ganglia, 
or  knots  along  its  course.  In  using  the  term,  "abdominal  brain,"  I  mean  to 
convey  the  idea  that  it  is  endowed  with  the  high  powers  and  phenomena  of 
a  great  nervous  center;  that  it  can  organize,  multiply  and  diminish  forces. 
The  views  which  I  wish  to  bring  forward  concern  the  periphery  of  the 
abdominal  brain,  or  the  mechanism  found  in  each  viscus.  I  mean  by  viscera 
those  organs  contained  in  the  chest  and  abdomen. 

During  the  investigation  of  the  sympathetic  I  selected  a  spare  female 
cadaver,  that  of  a  woman  about  thirty  years  of  age,  amputated  the  thighs 
close  to  the  body,  and  then  placed  it  in  full  strength  alcohol.  For  nearly 
two  years  I  dissected  on  this  cadaver,  as  I  found  time,  and  finally,  after 
tedious  labor,  dissected  out  all  the  visible  sympathetic  nerves  which  lay  on 
the  dorsal  region,  in  both  chest  and  abdomen,  returning  the  cadaver  to  the 
alcohol  when  not  using  it.       I  then  secured  a  skilled  artist,  who  worked  on 


166 


THE  ABDOMIXAL  AXD  PELVIC  BRA1X 


the  drawing  of  the  sympathetic  nerve  about  five  weeks,  sketching  it  as 
nearly  according  to  nature  as  it  was  possible,  and  exactly  life  size.  The 
most  important  portions  of  the  nerve  are  represented  in  the  cuts  accompany- 
ing this  work. 

Before  discussing  other  subjects  I  wish  to  make  a  few  remarks  on  three 
exaggerated  ganglia  of  the  sympathetic  nerve,  viz.  :  the  cervical,  the  abdomi- 


ABDOMIXAL  BRAIN  AND  CCELIAC  AXIS 

Fig.  46.     This  cut  represents  the  vaso-motor  nervo  supply  to  :  (a)  liver;   (b)  spleen;   (c) 
stomach ;   (d)  kidney. 


nal  and  the  pelvic.  It  is  easy  to  dissect  out  the  cervical,  and  especially  the 
large  upper  cervical,  which  is  about  one  and  one-half  inches  long.  It  is 
very  variable  and  appears  to  shrink  a  little  with  age,  after  forty.  The 
middle  cervical  is  often  so  small  that  it  is  difficult  to  expose.        The  lower 


GENERAL   CONSIDERATIONS  167 

cervical  is  often  difficult  to  dissect  and  isolate  on  account  of  complicated 
relations,  and  also  because  it  is  so  widely  spread  out,  so  fenestrated  and 
because  its  parts  vary  so  much.  The  abdominal  brain  is  quite  easy  to  isolate, 
especially  in  a  fresh  cadaver.  The  best  way  to  dissect  and  expose  it  well, 
without  mutilating  the  body  badly,  is  to  tear  through  the  ligamentum  gastro- 
coelicum  and  pass  to  the  cceliac  axis.  Then,  with  a  forceps,  clear  away  the 
tissue  just  above  the  middle  of  the  upper  border  of  the  pancreas,  i.e.,  at  the 
right  and  left  of  the  coeliac  axis. 

In  searching  for  the  abdominal  brain  it  is  best  to  strike  for  the  entering 
great  splanchnic  nerve  and  then  follow  it  to  the  side  of  each  ganglion.  On 
the  left  will  be  found  a  large  retort-shaped  solid  ganglion  of  a  pinkish  gray 
color.  On  the  right  of  the  cceliac  axis  is  found  a  wide,  flattened,  much 
fenestrated  ganglion.  Both  are  well  supplied  with  blood  The  most 
difficult  great  ganglion  to  isolate  and  expose  in  a  natural  condition  is  the 
uterine  ganglion  or  pelvic  brain.  It  is  very  large,  much  fenestrated,  quite 
flattened  and  richly  attached  to  the  second  and  third  sacral  (spinal)  nerves. 
It  is  situated  close  to  the  neck  of  the  uterus  and  sends  numerous  nerves  to 
this  organ  and  the  bladder.  It  requires  much  uninterrupted  leisure  to  isolate 
the  pelvic  brain  and  such  efforts  are  almost  always  a  failure  in  tat  subjects. 
The  cause  of  this  difficulty  in  isolating  the  pelvic  brain  lies  in  the  fact  that 
it  is  whiter  than  the  other  great  ganglia  and  more  like  the  surrounding 
connective  tissue,  with  which  it  is  intimately  blended  and  in  which  it  is 
imbedded;  also  because  it  is  so  much  flattened  out.  Probably  more  disputes 
have  arisen  over  the  cervico-uterine  ganglion  than  any  other  in  the  body. 
However,  the  cut  of  the  pelvic  brain,  here  presented,  the  author  considers 
quite  close  to  nature. 

In  each  of  the  viscera  are  found  small  nervous  ganglia  scattered  through 
the  organ,  or  the  nervous  bulbs  are  gathered  in  distinct  localities  of  the 
viscus,  as  in  the  heart  or  digestive  tract.  Now  it  may  be  understood  that 
these  little  ganglia  found  in  the  organs  have  the  power  to  maintain  move- 
ments to  some  extent.  These  peripheral  ganglia  may  be  looked  upon  as 
little  brains  which  are  capable  of  developing  nerve  force  and  communicating 
it  to  the  organs  without  the  aid  of  the  cerebro-spinal  axis.  They  can  multiply 
or  diminish  nerve  force,  which  is  sent  to  a  viscus  where  they  exist.  Diseases 
of  any  viscus  or  disturbance  of  its  rhythm  must  be  due  to  them  or  to 
abnormal  forces  passing  through  them,  arising  from  the  abdominal  brain. 
Again,  the  rhythm  and  function  of  a  viscus  are  involuntary,  i.e.,  beyond 
control  of  the  will.  They  are  automatic  nerve  centers  placed  in  the  viscus 
in  order  to  isolate  it  from  the  control  of  man's  mind.  These  little  brains 
induce  the  viscera  to  perform  their  functions  independent  of  the  state  of 
mind.  They  exclude  the  mind  from  speculating  on  the  viscus  so  far  as 
regards  function.  The  will  cannot  induce  the  ganglia  to  do  two  years'  work 
in  one,  or  one  year's  work  in  two.  The  peripheral  ganglia  of  every  viscus 
assumes  its  own  time  of  rhythm.  The  ganglia  of  each  viscus  rise  to  a 
maximum  and  sink  to  a  minimum  according  to  their  own  law  of  existence. 
They  go  through  a  rhythmical  movement,   ar  peculiar  cycle.       There  are 


168  THE  ABDOMINAL  AND  PELVIC  BRAIN 

explosions  of  nervous  energy  from  the  ganglia  during  regular  periods  of  time. 
For  example,  the  heart  ganglia  thus  explode  a  little  oftener  than  once  a 
second,  while  those  of  the  oviducts  and  uterus  explode  once  a  month.  They 
are  automatic  visceral  ganglia. 

We  will  consider  the  peripheral  apparatus  of  the  heart,  lungs,  uterus 
and  oviducts,  liver,  spleen,  kidneys,  bladder  and  digestive  tract.  A  study  of 
the  ganglia  in  each  organ  will  enable  one  to  diagnose  disease  in  the  said 
viscus. 

1.  The  peripheral  ganglia  have  been  well  studied  and  some  of  the 
more  important  ganglia  of  the  heart  substance  have  received  definite  names. 
The  little  brains  in  the  heart  are  called  automatic  cardiac  ganglia.  They 
are  named  the  automatic  centers  of  Remak,  Bidder,  Ludwig  and  Schmidt. 
These  are  simply  some  of  the  more  important  automatic  motor  centers  of 
the  heart.  In  many  experiments  on  dogs  I  have  repeatedly  satisfied  myself 
that  the  automatic  cardiac  ganglia  are  mainly  aggregated  in  the  auricles  and 
auricular-ventricular  septum.  Wherever  the  automatic  motor  centers  are 
located  in  the  heart  anyone  can  satisfy  himself  that  these  ganglia  excite  and 
maintain  the  rhythm  of  the  heart.  The  frog's  heart  can  be  kept  in  rhythmi- 
cal motion  by  stimulation  in  warm  salt  water  for  hours  after  it  has  been 
removed  from  the  body.  A  few  experiments  on  animals  will  soon  convince 
one  that  the  peripheral  ganglia  of  the  sympathetic  nerve  located  in  the  heart 
are  a  very  significant  apparatus  as  regards  the  cardiac  functions.  The  dis- 
turbance of  the  heart's  rhythm  by  uterine  disease  is  what  we  shall  attempt  to 
demonstrate  in  its  appropriate  place.  The  most  striking  peripheral  appara- 
tus of  the  sympathetic  nerve  is  found  in  the  heart.  Its  rhythm  is  so  perfect, 
its  cycle  is  so  apparent  and  its  explosion  so  manifest,  that  men  sought  its 
origin  outside  the  cerebrum.  The  dominating  influences  of  the  automatic 
motor-centers  on  the  heart  are  shown  by  the  idea  that  in  the  living  fetus, 
without  brain  or  spinal  cord,  the  heart  keeps  up  its  rhythmic  beat.  In  such 
fetuses  the  heart  ganglia  are  well  developed.  One-half  of  the  spinal  cord 
has  been  removed  in  pigeons  without  disturbing  the  cardiac  beat.  Besides, 
the  inferior  cervical  ganglion  has  very  intimate  connections  with  the  great 
ganglion  of  Wrisberg. 

2.  The  peripheral  apparatus  of  the  sympathetic  nerve  is  very  prominent 
in  the  digestive  tract.  The  digestive  tract  consists  of  a  muscular  and  a 
glandular  apparatus.  The  muscular  apparatus  of  the  digestive  tract  consists  of 
a  longitudinal  and  a  circular  layer,  and  between  these  two  muscular  layers  lies 
a  system  of  nervous  ganglia  known  as  Auerbach's  plexus.  Auerbach's  plexus 
is  the  peripheral  apparatus  that  induces  muscular  movements  in  the  gastro- 
intestinal passage.  These  little  brains  lying  between  the  muscular  layers  are 
the  cause  of  intestinal  peristalsis  or  vermicular  movements  of  the  bowels. 
Undue  stimulation  of  Auerbach's  plexus  causes  colic,  and  insufficient. stimula- 
tion is  followed  by  constipation — a  muscular  paresis.  An  insufficient  activity 
in  Auerbach's  plexus  induces  a  kind  of  ileus  paralyticus. 

Just  under  the  mucous  membrane  of  the  digestive  tract  there  lies  a  still 
more  delicate  system  of  nerve" ganglia  called  Meissner's  plexus.       Dr.  D.  D. 


NERAL   CONSIDERATIONS  169 

Bishop,  late  histologist  to  Rush  Medical  College,  has  prepared  for  me  very 
beautiful  specimens  of  Auerbach's  and  Meissner's  plexus  from  dogs,  by  the 
gold-staining  method.  These  plexuses  preside  over  the  production  of  the 
secretions  of  the  gastro-intestinal  passage.  The  office  of  these  little  brains 
is  really  to  control  glandular  secretion.  The}7  induce  the  secretion  of 
digestive  fluids.  They  assume  the  office  of  regulating  the  proper  amount 
of  fluids  to  digest  the  various  foods,  which  office  requires  a  nice  balance. 
Hence,  Auerbach's  and  Meissner's  plexuses  are  the  distinct  and  marked 
peripheral  apparatuses  of  the  digestive  tract.  Now  these  little  brains, 
situated  in  the  intestinal  wall,  have  an  action  quite  independent  of  the  cerc- 
bro-spinal  axis.  I  have  often  chloroformed  a  dog  and  then  watched  the 
intestines  perform  their  peristalsis  after  being  tapped  with  a  scalpel.  If  the 
dog  is  kept  in  a  warm  room,  the  intestine  will  go  through  its  peristaltic 
motion  for  an  hour  and  a  half  after  death.  The  peristalsis  will  be  strong 
and  very  marked.  Half  an  hour  after  death,  it  will  be  so  strong  that  the 
circular  muscles  of  the  intestine  will  contract  so  as  to  look  like  pale  white 
cords,  or  bands,  around  the  intestine.  Auerbach  s  and  Meissner's  plexuses 
are  what  induce  rhythm  in  the  bowel.  The  presence  of  food,  of  course, 
gives  the  occasion  for  rhythm.  Hence,  we  must  look  to  the  peripheral 
nervous  apparatus  of  the  digestive  tract  when  colic,  indigestion,  diarrhea 
and  constipation  arise,  for  these  little  brains  induce  motion  and  secretion  in 
the  bowel.  Of  course  they  are  under  the  physiological  and  anatomical 
orders  of  the  abdominal  brain — a  higher  central  organism.  The  pathology 
of  Meissner's  plexus  is  shown  in  (a)  deficient  secretion,  (b)  excessive  secre- 
tion and  (c)  disproportionate  secretion;  that  of  Auerbach's,  in  paralysis  or 
contraction  (colic). 

3.  The  peripheral  nervous  apparatus  of  the  generative  organs  is  located 
along  the  oviducts  and  uterus.  I  named  these  fifteen  years  ago,  "automatic 
menstrual  ganglia."  These  ganglia  can  easily  be  demonstrated  by  taking  a 
fresh  oviduct  from  the  abdomen  and  putting  it  in  warm  salt  water.  If  the 
oviduct  is  teased  and  stimulated  it  will  go  through  a  peristaltic  motion  for 
half  an  hour.  It  is  easy  to  observe  the  longitudinal  muscles  of  the  oviduct 
elongate  and  contract,  still  easier  to  watch  the  circular  muscles  of  the 
oviduct  contract  and  dilate.  I  have  made  this  experiment  often  enough  in 
men  and  animals  to  be  thoroughly  satisfied  of  the  existence  of  the  peripheral 
ganglia  in  the  oviducts  and  uterus. 

The  automatic  menstrual  ganglia  have  a  monthly  rhythm.  They  rise  to 
the  maximum  and  sink  to  the  minimum  every  four  weeks.  The  ganglia  exist 
in  the  uterus,  and  I  have  found  the  proof  of  this  to  be  most  easily  demon- 
strated in  the  pregnant  uterus  of  slaughtered  cows,  where  my  attention  was 
first  directed  to  the  matter.  Anyone  can  witness  it  in  a  slaughter-house. 
When  a  well-advanced  pregnant  uterus  of  a  cow  is  cut  off  between  the  body 
and  the  internal  os,  a  most  wonderful  rhythmic  phenomenon  is  observed. 
The  cow  may  have  been  dead  half  an  hour,  yet  the  two  muscular  layers  of 
the  uterus  can  be  seen  to  act  separately  and  vigorously.  At  one  time  the 
circular  muscles  will  contract  vigorously,  and  then  the  longitudinal  muscular 


iro 


I  ABDOMIXAL  AXD  PELVIC  BRAIX 


fibers  will  contract  with  equal  vigor.  Then,  again,  both  the  layers  will  work 
harmoniously  together.  The  irregular  action  of  the  muscular  layer  is  due 
to  the  irregular  traumatic  stimulus  applied  to  the  uterus.  The  rhythmical 
motion   applies  only  to   the  oviducts   and   uterus.     The   neck  of  the  uterus 


\M^M'  '■ W%  W  1M '  W 


PELVIC  BRAIN 
genifalH.47"     ""^  ""  repreSent5  the  vaso-motor  nerve   (sympathetic)  supply  to  the  tractus 

does  not  go  through  rhythmical  motion,   because  it  is    highly    supplied    by 
sacral  spinal  nerves.     The  spinal  nerves  prohibit  rhythm. 

The  sympathetic  nerves  which  supply  the  neck  do  try  to  make  rhythm 
but  the  spinal  nerves  to  the  neck  predominate  and  sober  down  all  rhythm. 
Hence,  the  predominating  spinal  nerve-supply  holds  the  neck  in  sober," quiet 


GENERAL   COXSIDERATIOXS  171 

subjection  and  allows  no  such  wavy  rhythm  as  goes  on  continually  in  the 
pregnant  uterus.  In  this  idea  lies  a  great  principle  in  gynecology.  The 
neck  of  the  uterus  acts  as  its  guard  when  pregnant.  The  waves  of  its 
rhythm  may  dash  and  sport  as  they  choose,  yet  the  neck  stands  on  sober 
guard  and  permits  no  expulsion  of  the  contents.  The  neck  is  never  prepared 
for  an  abortion,  but  stands  like  an  unmoved  sentinel,  so  that  no  storm-waves 
of  the  uterus  can  drive  out  its  contents  or  allow  foreign  invasion.  The 
offices  of  neck  and  uterus  are  quite  different.  The  neck  has  a  different  blood 
supply,  a  different  nerve  supply,  a  different  muscular  supply,  and  a  dis- 
tinct mucous  membrane.  It  keeps  out  foreigners  and  prevents  desertion. 
The  nerve  supply  of  the  ovary  is  mainly  from  the  ovarian  sympathetic,  but 
as  I  have  so  far  been  unable  to  determine  the  rhythm  of  ovulation,  I  will 
investigate  that  later.  Suffice  it  to  say  that  menstruation  and  ovulation,  so 
far  as  I  have  studied,  are  different  processes,  and  hence  have  a  different 
rhythm.  The  menstrual  rhythm  is  a  matter  belonging  entirely  to  the 
monthly  movements  of  the  oviducts  and  uterus.  Menstruation  might  be 
called  oviductal  motion  or  the  rhythmic  effect  of  the  action  of  the  automatic 
menstrual  ganglia.  The  menstrual  rhythm  is  an  occasional  process  of  the 
uterus  and  oviducts,  but  ovulation  is  a  constant  process  of  the  ovaries,  whose 
distinct  rhythm  is  yet  to  be  determined.  So  far  I  have  been  utterly  unable 
to  determine  the  age  and  duration  of  the  life  of  a  Graafian  follicle,  for  I  have 
seen  ovulation  in  unborn  babes  and  in  women  of  seventy.  I  have  examined 
pigs,  cows  and  sheep  and  found  that  all  ovulated  before  birth.  Ovulation 
continues  from  before  birth  until  the  ovarian  tissue  is  worn  out. 

I  assume,  then,  that  the  peripheral  nerve  apparatus  in  the  organs  of 
generation  is  a  distinct  affair,  which  I  designated  fifteen  years  ago  as  the 
"automatic  menstrual  ganglia."  Its  mechanism  is  such  as  to  subserve  the 
function  of  reproduction  through  a  peculiar  rhythm.  The  monthly  rhythm 
in  pregnane}'  is  held  in  abeyance  on  account  of  the  direction  of  energy  to 
fetal  nutrition.  The  derangement  of  the  function  of  the  automatic  menstrual 
ganglia  will  engage  our  attention  later.  Any  disturbance  in  these  ganglia 
gives  us  a  clue  to  the  diagnosis  of  the  disease. 

We  will  term  the  small  nerve  bulbs  situated  in  the  walls  of  the  bladder 
the  automatic  vesicular  ganglia.  The  peripheral  nervous  apparatus  located 
in  the  bladder  is  markedly  sympathetic,  and  hence  will,  like  other  viscera, 
have  its  rhythm.  The  rhythm  of  the  bladder  is  its  contraction  and  dilata- 
tion. It  has  a  diastole  and  systole.  Its  rhrythm  is,  to  some  extent,  lost  sight 
of,  because  the  diastole  is  so  much  longer  than  the  systole.  It  requires  hours 
for  the  diastole  to  complete  itself,  while  the  systole  may  be  completed  in  a 
few  minutes  or  less.  But  the  rhythm  of  other  viscera,  as  the  heart,  is  not 
dissimilar.  The  heart  has  a  diastole  and  a  systole,  and  the  diastole  of  the 
ventricle  is  two-tenths  of  a  second  longer  than  the  systole.  The  diastolic 
wave  of  the  heart  is  the  time  when  the  heart  gets  its  rest — physiologically 
and  anatomically.  The  bladder  has  just  as  much  rhythm  as  the  heart,  only 
it  is  not  so  strikingly  manifested.  The  bladder  gets  an  effectual  rest  during 
its  long  diastole.       By  careful  dissection  of  a  goodly  number  of  bodies    it 


172  THE  ABDOMIXAL  AND  PELVIC  BRAIN 

can  be  clearly  seen  that  the  third  sacral  nerve  of  each  side  sends  quite  large 
branches  to  the  bladder.  The  fourth  sacral  nerve  also  sends  branches 
to  the  bladder.  Under  such  circumstances  the  bladder  is  highly  sup- 
plied with  spinal  sacral  nerves,  which  would  sober  down  the  rhythm  and 
prevent  it  as  much  as  possible.  The  sacral  spinal  nerves  distributed  to  the 
bladder  go  mainly  to  the  neck,  while  the  sympathetic  mainly  supply  the 
fundus — the  rhythmical  portion. 

This  rhythm  is  easily  demonstrated  by  taking  the  bladder  from  an  ox 
and  filling  it  with  fluid.  The  contraction  of  its  muscular  wall  will  soon 
change  the  shape  and  gradually  expel  its  contents.  The  neck  of  the  bladder 
is  more  supplied  with  sacral  spinal  nerves  than  the  body.  In  short,  the 
great  nerve  center  of  the  bladder  is  in  the  trigone.  Hence,  in  pregnancy 
the  disturbance  in  the  bladder  is  due  to  the  uterus  dragging  on  the  neck  of 
the  bladder  where  its  sensitive  (spinal)  nerves  exist.  The  female  bladder  is 
capable  of  retaining  urine  longer  than  the  male  bladder,  as  the  neck  of  the 
former  is  not  so  fixed  and  hence  is  not  dragged  on  as  much  when  filling. 
The  neck  of  the  male  bladder  is  fixed  with  the  prostatic  capsule,  and  when 
filled  drags  more  or  less  on  a  fixed  neck  and  so  irritates  the  attending  nerves. 
The  peripheral  ganglia  of  the  bladder  are  mainly  distributed  to  the  fundus 
and  bod}r.  The  diastole  of  the  bladder  during  sleep  is  prolonged  on  account 
of  the  quietude  of  the  sympathetic.  The  peripheral  ganglia  in  the  bladder, 
the  automatic  vesical  ganglia,  have  not  received  much  study  so  far. 

4.  The  peripheral  nervous  apparatus  of  the  lung  I  have  not  especially 
investigated.  That  the  lungs  have  an  established  rhythm  is  plain,  which  no 
doubt  is  maintained  by  the  ganglia  situated  in  their  substance.  The 
peripheral  ganglia  should  be  called  the  automatic  pulmonary  ganglia.  No 
doubt  there  also  exists  a  conjoined  cerebro-spinal  center. 

5.  The  peripheral  nervous  apparatus  of  the  liver  may  not  at  first  sight 
seem  manifest.  But  the  liver  is  enormously  supplied  by  the  sympathetic, 
the  nerve  of  rhythm.  The  liver  is  a  gland,  and  one  who  has  made  a  study  of 
the  peripheral  ends  of  the  sympathetic  will  have  noticed  that  where  it  ends  in 
muscular  organs  the  ganglia  are  large  and  manifest.  But  when  it  ends  in 
glands  it  forms  a  fine  and  delicate  plexus  of  nerves.  In  the  liver,  the 
ganglia  are  less  apparent  than  the  plexus  which  follows  the  fine  vessels  all 
through  the  liver.  The  caliber  of  these  small  vessels  is  subject  to  dilatation 
and  contraction — rhythm.  Every  visceral  organ  during  activity  is  in  a  state 
of  vascular  congestion — a  condition  of  turgescence  or  enlargement.  The 
surrounding  of  each  viscus  in  the  abdomen  is  such  that  it  can  be  rapidly 
enlarged  during  its  functional  activity,  and  it  returns  to  normal  without  loss 
of  integrity.  Now,  the  rhythm  of  the  liver  consists  of  its  enlargement 
during  functional  activity  and  its  return  to  normal  during  rest.  The  rhythm 
of  the  liver  is  made  possible  by  (a)  the  elasticity  of  the  peritoneum  which 
surrounds  it;  (b)  by  its  surrounding  elastic  capsule;  (c)  by  the  elastic  tissue 
in  Glisson's  capsule  which  surrounds  the  vessels  throughout  the  liver,  and 
(d)  by  the  dilatability  of  the  blood  vessels. 

Hence,  the   liver   gland    is   capable    of    enlargement  and  contraction — 


GENERAL   CONSIDERATIONS  173 

rhythm — from  the  possession  of  elastic  tissue,  and  by  engorgement.  When 
the  liver  is  functionally  active  it  becomes  turgescent,  or  engorged,  and  its 
envelopes  or  capsules  expand  from  elastic  properties.  When  the  liver  goes 
through  its  active  rhythm  its  vascular  excitement  attracts  large  quantities  of 
iluid,  from  which  it  makes  bile,  glycogen  and  urea;  it  then  returns  to  its 
normal  condition  because  the  elastic  capsule  forces  the  newly-formed 
products  through  the  tubules  to  be  employed  in  digestion.  The  liver  in  its 
quiet,  reduced  form  gets  self-repair.  Thus  the  liver  goes  through  its  rhythm 
of  enlargement  (functional  activity)  and  of  contraction  (self-repair,  rest). 
The  occasion  of  a  rhythm  of  a  liver  is  food  in  the  digestive  tract.  It  is  the 
derangement  of  the  rhythm  of  the  liver  by  uterine  disease  which  we  will  call 
attention  to  later.  The  derangement  of  the  liver  rhythm  will  change  the 
three  great  functions  of  the  gland,  which  are  to  make  bile,  glycogen  and 
urea.  The  derangement  is  brought  about  by  disturbing  the  equilibrium  of 
the  abdominal  brain.  We  will  term  the  peripheral  nerve  apparatus  in  the 
liver  the  automatic  hepatic  ganglia.  The  derangement  of  these  is  manifested 
by  (a)  a  deficient  secretion  (bile,  glycogen  and  urea) ;  (b)  excessive  secretion, 
and  (c)  by  disproportionate  secretion,  especially  the  last. 

6.  The  spleen  has  a  peripheral  nervous  apparatus  which  enables  it  to  do 
its  duty  ic  a  rhythmic  wave.  In  the  case  of  the  spleen  the  elastic  capsule, 
to  which  is  added  involuntary  muscular  fibers,  enables  the  organ  to  enlarge 
during  functional  activity  and  then  to  be  reduced  by  elastic  pressure  to  its 
normal  size.  Engorgement  and  elasticity  are  the  two  elements  which  aid  to 
complete  the  rhythm  of  the  spleen. 

Vascular  excitement,  with  dilatations  and  turgescence,  characterizes  the 
functional  activity  and  enlargement  of  the  spleen.  Its  capsule  expands. 
Contraction  of  the  elastic  capsule  and  muscle  fiber  in  it  characterizes  the 
reduction  of  the  spleen.  Its  rhythm  is  made  up  of  its  active  enlargement 
and  its  passive  reduction.  In  the  maximum  stage  of  the  rhythm,  the  spleen 
performs  its  functions,  and  in  the  minimum  stage  it  gets  its  rest  and  self- 
repair.  A  curious  feature  is  added  to  the  spleen  in  the  form  of  a  tortuous 
artery.  The  object  of  this  spiral  artery  must  be  to  withstand  sudden  motion  or 
enlargement,  for  when  the  spleen  is  large  the  artery  is  just  as  spiral  as  it  is 
in  the  enlarged  uterus.  But  it  may  be  that  the  tortuous  artery  allows  a 
greater  flow  of  blood.  Hence,  the  spleen  performs  its  rhythm  from  the 
peripheral  nervous  apparatus  situated  in  its  substance.  The  occasion  of  its 
rhythm  must  be  the  same  as  that  of  the  stomach  and  liver — fresh  food.  We 
will  term  this  nervous  apparatus  the  automatic  splenic  ganglia. 

7.  The  same  reasoning  applies  to  the  rhythmic  functions  of  the  pancreas 
and  kidney,  and  also,  probably,  to  the  ovary.  They  come  under  the  law  of 
vascular  engorgement  and  elastic  capsule,  which  enable  the  automatic  periph- 
eral ganglia  to  produce  and  sustain  a  rhythm.  We  thus  have  the  auto- 
matic renal,  and  also  the  automatic  pancreatic,  ganglia. 

(1)  We  have  tried  to  establish  the  view  that  the  abdominal  brain  is  the 
great  nerve  center  of  the  abdominal  viscera  and  perhaps  of  the  thoracic 
viscera ;  (2)  that  it  is  the  cause  of  visceral  rhythm ;  (3)  that  each  viscus  has 


174 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


its  own  automatic  peripheral  ganglia  or  plexuses  in  the  organ;  (4)  that  the 
duration  of  the  rhythm  of  each  viscus  is  determined  by  the  mechanism  of 
the  automatic  ganglia  situated  in  the  organ. 

The  rock  and  base  view  maintained  in  this  book  is,  that  the  abdominal 


DUCTUS  BILIS  AND  DUCTUS  PANCREATICUS 

Fig.  48.  This  cut  represents  an  X-ray  of  the  ducts  of  the  liver  and  pancreas.  Each 
duct  is  ensheathed  by  an  anastomosed,  nodular,  'fenestrated  meshwork  of  nerves  which 
demonstrates  the  enormous  nerve  supply.  This  is  in  addition  to  the  nerve  supply  en- 
sheathing  the  arteria  hepatica. 

brain  is  a  reorganizing  nerve  center— a  brain,  a  cerebrum.  The  abdominal 
brain  is  capable  of  reception,  reorganization  and  emission  of  nerve  forces 
involving  the  life  of  viscera  (which  consists  of  rhythm,  absorption  and 
secretion).  The  emission  of  nerve  forces  will  travel  as  a  maximum  to  organs 
possessing  the  greatest  number  of  nerve  strands,  e.g.,  the  genitals,  kidney. 


GENERAL   CONSIDERATIONS  175 

heart  and  stomach,  and  as  a  minimum  to  organs  possessing  the  least  number 
of  nerve  strands. 

Having  planted  our  orchard  we  will  examine  its  fruits.  We  now  come 
to  the  application  of  these  views  to  the  subject  of  disease.  Disease  of  any 
of  the  viscera  will  very  often  be  preceded  by  some  derangement  of  their 
rhythm,  absorption  or  secretion.  The  common  functions  of  viscera  are 
peristalsis  (rhythm),  absorption  and  secretion — all  dominated  by  the 
sympathetic  nerve,  i.e.,  the  abdominal  brain.  To  the  common  functions  of 
viscera  (peristalsis,  absorption  and  secretion)  must  be  added,  in  the  genital 
tract,  ovulation,  gestation  and  menstruation. 

The  two  great  factors  in  visceral  diseases,  so  far  as  regards  the  sympa- 
thetic nerve,  are  (1)  impaired  nutrition,  and  (2)  reflex  action,  referred  pain 
or  disturbance.  An  important  central  point  around  which  much  of  the 
abdominal  sympathetic  turns  is  the  female  generative  organs.  They  are 
the  one  cog  in  the  wheel  which  makes  the  watch  keep  defective  time. 

The  pathology  of  the  sympathic  nerve  is  not  so  distinctly  settled  as  that 
of  the  cerebro-spinal.  (1)  The  most  significant  pathology'  of  the  sympa- 
thetic is  reflex  irritation,  referred  disturbance.  (2)  Pigmentation  and 
sclerosis.  The  origin  of  the  pigmentation  is  primarily  in  the  spleen  and 
liver.  Pregnancies,  menstruation  (periodic  congestion),  fever  (malarial), 
etc.,  etc.,  are  accompanied  by  pigmentation.  This  may  be  due  to  a  diseased 
state  of  the  blood.  It  is  more  frequently  due  to  reflex  irritation  from  the 
distant  organs.  Some  consider  violent  emotion  as  a  cause  of  pigmentation, 
but  it  is  likely  that  it  refers  to  some  unrecognized  lesion.  (3)  The  third 
kind  of  pathology  of  the  sympathetic  would  be  lesions  secondary  to  those  of 
the  cerebro-spinal  system.  (4)  The  fourth  would  be  recognized  and  non- 
recognized  lesions  of  the  sympathetic.  I  have  not  space  here  to  discuss 
these  interesting  and  wide  pathological  fields,  but  simply  mention  them. 

Disturbances  in  the  Digestive  Tract  from  Uterine  Changes. — In  this 
case  we  have  immediate  and  remote  troubles  as  regards  time.  The  chronic 
uterine  disease  will  produce  remote  malnutrition  and  remote  reflex  changes. 
In  these  cases  I  mean  diseases  of  the  entire,  or  part  of  the  generative  appara- 
tus— Pudenda,  vagina,  especially  the  uterus,  oviducts  and  ovaries.  Take, 
for  example,  a  case  where  the  digestive  tract  is  deranged  on  account  of 
pregnancy.  In  the  first  place  the  vomiting  arises  from  trauma,  stretching 
on  the  uterine  nerves  by  an  expanding  foreign  body  (contents)  and  the 
dragging  of  the  neck  of  the  uterus  on  the  neck  of  the  bladder.  This  dragging 
or  pressure  on  the  neck  of  the  bladder  disturbs  the  spinal  and  sympathetic 
nerves  massed  there.  The  irritation  is  carried  up  the  hypogastric  plexus  to 
the  abdominal  brain.  When  the  irritation  arrives  at  the  abdominal  brain 
the  forces  are  reorganized  and  sent  out  on  the  various  nerve  plexuses  which 
radiate  from  this  nerve  center.  If  the  force  is  emitted  along  the  gastric 
plexus,  which  is  liable  to  happen  on  account  of  its  large  size,  the  stomach 
receiving  sympathetic  nerves  from  the  three  branches  of  the  celiac  axis,  the 
stomach  will  suffer  and  vomiting  is  likely  to  occur.  Now,  in  the  troubles  of 
the  stomach  resulting  from  reflex  disturbances  from  the  uterus  by  way  of  the 


176  THE  ABDOMINAL  AND  PELVIC  BRAIN 

hypogastric  plexus,  it  may  be  considered  that  the  stomach  is  affected  in  two 
distinct  parts;  (a)  its  muscular  wall  (Auerbach's  plexus),  (b)  its  glandular  or 
secretory  apparatus  (Meissner's  plexus).  When  the  irritation  from  the 
generative  organs  travels  up  the  hypogastric  and  ovarian  plexuses  'to  the 
abdominal  brain  it  is  then  reorganized  and  emitted  along  the  gastric  plexus  to 
the  automatic  gastric  ganglia,  known  as  Auerbach's  plexus.  It  affects 
Auerbach's  plexus  first  because  it  first  meets  it  in  the  muscles.  The  result  of 
irritation  of  Auerbach's  plexus  is  irregular  action  of  the  muscles  of  the 
stomach — nausea  or  vomiting.  When  the  irritation  goes  farther  along  the 
gastric  plexus  it  meets  Meissner's  plexus,  which  lies  just  beneath  the  mucous 
membrane,  and  controls  gastric  secretion.  If  Meissner's  plexus  is  consider- 
ably irritated  it  may  cause  excessive  or  deficient  secretion  of  the  fluids,  or  the 
fluids  may  be  secreted  in  disproportionate  quantities.  The  result  will  be  indi- 
gestion and  fermentation,  causing  the  development  of  gases. 

The  reflex  irritation  from  the  uterus  may  be  of  such  a  nature  that 
Auerbach's  plexus  may  be  insufficiently  stimulated,  causing  paresis  of  stomach 
wall,  or  that  Meissner's  plexus  is  so  little  stimulated  that  it  will  not  secrete 
sufficient  gastric  fluids.  But  the  track  of  the  nervous  irritation  is  definite  from 
the  generative  organs,  through  the  hypogastric  plexus,  to  the  abdominal  brain, 
where  it  is  reorganized  and  emitted  to  the  various  viscera.  This  is  the  inter- 
pretation of  the  old  story  that  uterine  disease  creates  stomach  trouble,  and 
vice  versa.  By  reference  to  a  cut  showing  the  pelvic  brain,  or  cervico-uterine 
ganglion,  one  can  see  at  once  the  extensive  nerve  supply  which  attends  the 
uterus.  It  may  be  observed  in  cases  of  violent  vomiting  that  digestion  and 
nourishment  are  quite  good.  The  reason  must  be  that  Auerbach's  plexus  is 
the  main  one  affected  (muscular),  while  Meissner's  (glandular),  the  one  which 
really  digests  the  food,  is  not  much  affected.  In  the  case  of  chronic  uterine 
disease  the  whole  subject  is  plain  and  practical.  Such  patients  have  malnu- 
trition for  several  years.  In  short,  it  is  noticeable  that  a  woman  will  apply 
for  treatment  of  uterine  disease  some  four  years  after  the  cervix  has  been 
lacerated.  The  illness  was  increasing  all  the  time,  the  last  part  being  more 
apparent.  In  stomach  troubles  from  chronic  disease  of  the  generative 
organs,  it  appears  that  Meissner's  plexus  is  affected  the  most,  as  such  patients 
seldom  vomit ;  but  they  do  not  digest  their  food,  which  is  performed  by  the 
gastric  fluid  secreted  by  the  influence  of  Meissner's  plexus  on  the  cardiac 
and  pyloric  glands. 

But  I  wish  rather  to  note  the  effect  of  chronic  disease  of  the  generative 
organs  on  the  enteron  intestines,  which  is  the  location  of  real  digestion.  The 
business  part  of  the  digestive  tract  is  the  enteron,  the  small  intestines — the 
jejunum  and  ileum.  The  enteron  is  supplied  by  the  superior  mesenteric 
artery,  and  along  this  artery  goes  the  great  superior  mesenteric  plexus  of 
nerves.  What  we  will  observe  is  the  mechanism  at  the  end  of  this  superior 
mesenteric  nerve,  viz.,  Auerbach's  plexus.  This  produces  bowel  peristalsis, 
rhythm. 

Take,  for  instance,  a  case  of  chronic  endometritis,  salpingitis  or  ovaritis 
of  several  years'  duration.    Disease  of  the  female  organs  is  a  slow,  continuous, 


GENERAL   COXSIDERATIOXS  177 

progressive  process.  It  is  a  kind  of  evolutionary  process  and  generally  should 
be  read  endometritis,  plus  myometritis,  plus  endosalpingitis,  plus  ovaritis, 
plus  as  much  peritonitis  as  the  infection  produces  at  the  ends  of  the 
oviducts.  Because  of  this  slow,  evolutionary  progress  of  female  disease  the 
effect  through  this  sympathetic  nerve  is  of  slow  progress  and  gradual.  The 
irritation  from  the  generative  organs  will  travel  to  the  abdominal  brain  by 
way  of  the  ovarian  and  hypogastric  plexuses.  It  is  a  common  observation 
that  gases  may"  develop  in  a  few  minutes  so  that  fermentation  is  not  the 
explanation  of  their  origin.  Some  attempt  to  explain  the  origin  of  this 
intestinal  gas  by  noting  that  it  collects  because  the  bowel  muscle  has  lost  its 
power  to  contract;  but  the  gas  develops  too  suddenly  for  this  theory  to  fit. 
If  the  irritation  from  the  uterine  disease  causes  Meissner's  plexus  to  secrete 
deficient  fluids,  indigestion  and  constipation  arise.  So  reflex  irritation  from 
the  generative  organs,  by  way  of  the  abdominal  brain  to  the  small  intestine  or 
enteron  can  act  in  two  ways:  (1)  It  may  so  stimulate  Auerbach's  plexus  in  the 
intestinal  wall  as  to  produce  colic, and  (2)  so  stimulate  Meissner's  plexus  as  to 
induce  excessive  secretion,  deficient  secretion  or  disproportionate  secretion. 
The  result  here  will  be  development  of  gases  and  diarrhea. 

The  abnormal  stimulation  of  Auerbach's  and  Meissner's  plexuses  may 
result  in  deficient  bowel  peristalsis  and  secretion  which  ends  in  constipation. 
The  final  result  of  these  is  indigestion  or  malnutrition.  Hence,  chronic 
uterine  disease  creates  its  disasters  on  the  system  really  by  malnutrition.  It 
disturbs  the  normal  visceral  rhythm.  Malnutrition  is  manifest  in  pregnancy, 
in  perceptible  disease  of  the  generative  organs,  and  at  the  menopause.  The 
explanation  lies  in  the  abnormal  irritation  of  the  nerves  in  the  generative 
organs,  which  is  reflected  through  the  abdominal  brain  to  the  digestive 
tract.  I  have  never  heard  or  read  of  the  method  herein  used  to  explain  the 
action  of  the  abdominal  brain  on  the  digestive  tract,  but  I  think  it  is  a 
practical  explanation.  These  views  explain  why  animals  or  man  lose  control 
of  the  bowels  under  fright.  The  violent  forces  emitted  from  the  abdominal 
brain  induce  excessive  activity  of  Auerbach's  plexus  (colic)  and  Meissner's 
plexus  (secretion)  and  a  sudden  diarrhea  results  in  the  animal.  In  other 
words,  under  high  emotional  influences  the  animal's  rectal  sphincters  are 
unable  to  resist  the  violent  bowel  peristalsis.  Peristalsis  is  stronger  than  the 
orificial  sphincters.  Involuntary  defecation  is  common  among  children  and 
animals  from  fright.  In  older  animals  the  cranial  brain  assumes  more  influ- 
ence over  the  abdominal  brain,  i.  e.,  it  sobers  down  its  violent  and  irregular 
rhythm.  Chronic  disease  of  the  generative  organs  creates  malnutrition  in 
the  digestive  tract  by  disturbing  its  normal  functional  rhythm  and  by  reflect- 
ing irregular  rhythms  into  the  digestive  tract  during  its  times  of  rest  and 
repose.  It  does  not  matter  what  the  disease  of  the  generative  organs  is,  so 
that  irritation  arises  and  is  reflected  to  the  abdominal  brain.  Inflammation, 
tumors  or  the  local  manifestations  of  the  menopause,  will  act  similarly, 
according  to  the  degree  of  irritation.  The  subject  may  be  considered  in  the 
following  short  summary: 

The  reflex  irritation  of  the  abdominal  brain  will  cause  Meissner's  plexus 


178 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


to  secrete  (a)  too  much  secretion  (diarrhea),  (b)  too  litte  secretion  (constipa- 
tion) or  (c)  disproportionate  secretion  (fermentation).  The  same  thing  will 
occur  in  any  secondary  organ,  i.  e.,  too  much,  too  little  or  disproportionate 
secretion.  Now,  I  will  point  out  a  matter  which  long  puzzled  me,  viz.,  a 
woman  who  has  a  lacerated  cervix  will  go  through  various  pathological  stages 
for  some  five  years  and  end  as  a  confirmed  neurotic.  I  have  observed  it  for 
years,  and  the  order  of  occurrences  is  as  follows: 

1.  The  first  stage  is  irritation.  The  irritation  does  not  arise  so  much 
from  the  lacerated  cervix  as  from  the  endometrium  (infection  atrium).  The 
irritation  keeps  up  for  years,  endometritis,  myometritis,  endosalpingitis. 

2.  The  second  stage  is  indigestion.  The  long-continued  irritation 
arising  from  the  genitals  and  passing  up  to  the  abdominal  brain,  and  being 


CORROSION  ANATOMY    OF  THE  KIDNEY 

Fig.  49.  This  cut  represents  the  rich  renal  arterial  supply.  Each  arterial  branch  is 
ensheathed  by  an  anastomosed,  nodular  meshwork  of  nerves  which  indicates  the  quantity  of 
vaso-motor  nerves  attending  the  renal  organ  and  its  duct  (ureter). 

there  recognized  and  sent  out  on  the  plexuses  of  Meissner  and  Auerbach  of 
the  digestive  tract,  soon  causes  too  much  secretion,  too  little  secretion  or 
disproportionate  secretion,  which  results  in  indigestion. 

3.  The  third  stage  is  malnutrition.     Long-continued  indigestion  simply 
results  in  malnutrition.     The  reflex  irritation  goes  on  continually. 

4.  The   fourth   stage   is   anemia,    resulting   from   the   indigestion   and 
malnutrition. 

5.  The   fifth  and   last  stage  is  neurosis,    which  is   due  to  the  nervous 
system  having  been  bathed  in  waste-laden  blood  for  years,  neurosis,  psychosis. 

Hence,  a  patient  with  laceration  of  the  cervix  passes  through  five  stages: 


GENERAL   CONSIDERATIONS  17<j 

(1)   irritation  (infection);  (2)   indigestion;  (3)   malnutrition;  (4)  anemia;  (5) 
neurosis,  psychosis. 

We  will  now  consider  the  liver  as  disturbed  by  disease  of  the  generative 
organs,  whether  it  be  acute  or  chronic.  We  noted  that  the  liver  was  highly 
supplied  with  sympathetic  nerves;  that  it  had  a  peripheral  plexus  in  its  sub- 
stance. This  we  will  style  the  automatic  hepatic  plexus.  We  noticed  that 
the  liver  was  induced  to  perform  a  rhythm  by  its  automatic  plexus,  and  that 
its  rhythm  was  made  possible  by  the  elasticity  of  its  capsules,  the  tissue 
which  governs  its  expansion  and  contraction  (rhythm)  being  elastic  and 
contractile.  Rhythm  of  the  liver  is  made  up  of  two  distinct  stages,  a  time 
of  activity  (parenchymal  secretion)  and  a  time  of  repose.  Its  stage  of  func- 
tional activity  is  when  its  capsules  are  expanding  under  the  vascular  excite- 
ment of  turgescence,  the  products  of  cell-work,  bile,  glycogen  and  urea  being 
secreted.  Its  stage  of  repose  and  self-repair  is  when  its  capsules  are 
contracting,  and  the  blood-vessels  are  being  depleted,  the  contracting  capsule 
having  partly  forced  the  cell  products  (bile,  glycogen  and  urea)  into  other 
regions  and  organs  to  accomplish  their  final  object.  By  means  of  this  rhythm 
the  liver  secures  a  stage  of  activity  and  a  stage  of  rest. 

It  is  plain  why  the  liver  suffers  so  badly  among  liquor  drfnkers.  The 
drinker  has  no  regard  for  the  time  of  rest  of  his  liver,  so  he  takes  his 
stimulant  especially  at  times  when  the  liver  is  at  rest.  The  irritating  fluids 
pass  by  way  of  the  gastric  portal  veins  into  the  quiet,  resting  liver  and  of 
course  excite  it  to  go  through  a  rhythm  at  any  time.  Thus  the  drinker 
deprives  his  liver  of  the  needed  rest.  The  rhythm  of  the  liver  is  irregularly 
disturbed  and  that  calls  up  disease.  It  is  precisely  the  same  in  diseases  of 
the  generative  organs.  Irritation  starts  from  a  diseased  pelvis  and  travels 
up  the  ovarian  and  hypogastric  plexuses  to  the  abdominal  brain.  Hence, 
the  irritation  is  reorganized  in  the  abdominal  brain  and  emitted  along  the 
hepatic  plexus.  The  automatic  hepatic  plexus  is  unduly  and  irregularly  stim- 
ulated at  times  of  activity  and  rest.  The  result  is  that  the  rhythmical  func- 
tion of  the  liver  is  deranged.  The  nice  balance  of  its  formation  of  bile, 
glycogen  and  urea  is  destroyed. 

The  diseased  pelvic  organs  have  no  respect  for  liver  rest  and  they  send 
their  uncertain  reflexes  to  the  liver  at  unseemly  times.  Chronic  disease  of 
the  pelvic  organs  will  excite  impulses  which  travel  to  the  abdominal  brain, 
which  resends  them  to  the  liver  at  such  uncertain  times  that  the  liver  never 
performs  its  activity  or  rest,  without  more  or  less  attempt  to  induce  irregular 
rhythms.  The  final  result  is  that  the  rhythm  of  the  liver  is  disturbed  and  that 
the  cell-products  of  the  liver  are  formed  irregularly.  Bile,  glycogen  and  urea 
are  formed  excessively,  deficiently  or  disproportionately,  and  it  ends  in 
malnutrition.  The  skin  is  yellow  and^  sallow,  the  urinary  products  are 
abnormal.  Diseases  of  the  liver  are  manifest  during  pregnancy  in  demonstra- 
ble pelvic  diseases,  and  especially  is  this  true  at  the  menopause.  The 
anatomical  nerve  track  followed  by  irritation  from  the  generative  organs  to 
the  abdominal  brain,  and  thence  to  the  liver,  is  plain,  and  the  physiological 
results  show  the  theory  to  be  reasonable.     Right  here  we  may  say  that  liver 


180  THE  ABDOMINAL  AND  PELVIC  BRAIN 

disease  and  disease  of  the  digestive  tract  are  quite  common  at  the  menopause. 
The  explanation  of  this  is  not  difficult.  During  the  thirty  years  of  seedtime 
and  harvest  of  woman  the  abdominal  brain  emits  its  physiological  orders  to 
the  automatic  menstrual  ganglia,  situated  in  the  uterus  and  oviducts,  to  per- 
form their  rhythm  of  menstruation.  Thirty  years  of  rhythm  in  any  organ  will 
surely  form  a  habit  which  it  will  require  force  to  break.  When  the  menopause 
arrives,  which  occurs  suddenly,  the  old  beaten  paths  of  the  hypogastric 
plexus,  along  which  the  menstrual  orders  for  thirty  years  had  been  sent, 
are  suddenly  cut  off.  This  sudden  cutting  off  of  old  channels,  by  which 
forces  were  formerly  emitted,  is  bound  to  make  the  latter  accumulate  in  the 
central  organ  or  abdominal  brain.  Now,  these  accumulated,  unused  energies 
must  have  some  outlet  and  they  will  go  in  the  direction  of  least  resistance. 
The  great  channels  of  easy  outlet  of  pent-up  forces  in  the  abdominal  brain 
appear  to  be  the  gastric  and  superior  mesenteiic  plexuses,  which  supply  the 
digestive  tract,  and  the  hepatic  plexus.  Hence,  in  the  menopause  the 
accumulated  force  in  the  abdominal  brain  is  mainly  spent  on  the  digestive 
tract  and  liver.  The  accumulated  energies  go  to  these  in  an  irregular  manner 
and  thus  aid  in  disturbing  their  rhythm.  The  result  is  abnormal  products  in 
the  liver  (bile,  glycogen  and  urea),  and  for  the  digestive  tract,  indigestion 
(constipation  or  diarrhea). 

The  Jieart  of  woman  docs  not  escape  the  influence  of  the  chief  wheel  of  her 
existence.  It  has  very  manifest  peripheral  sympathetic  ganglia  and  is  largely 
under  the  control  of  the  sympathetic  nerve,  as  may  be  seen  from  its  nice 
rhythm.  Now,  from  each  of  the  three  cervical  sympathetic  ganglia  on  each 
side  of  the  neck  there  goes  a  nerve  to  the  heart  (the  heart  also  receives  three 
nerves  on  each  side  from  the  pneumogastrics).  When  the  pelvis  contains 
diseased  generative  organs,  the  irritation  arising  there  travels  up  the  ovarian 
and  hypogastric  nerves  to  the  abdominal  brain. 

From  the  abdominal  brain  two  roads  lead  to  the  heart.  One  road  is 
through  the  great  splanchnics  to  the  cervical  ganglia,  and  as  these  ganglia 
act  as  little  brains,  the  force  is  here  reorganized  and  sent  directly  to  the 
heart.  Of  course  all  irritation  comes  irregularly  and  so  aids  in  disturbing 
the  heart's  rhythm.  But  spinal  or  cranial  nerves  prohibit  rhythm,  so  I  think 
the  main  forces  from  the  abdominal  brain  travel  up  the  pneumogastrics  to 
the  fourth  ventricle)  and  the  irritation  is  then  reflected  directly  to  the  heart. 
Irritation,  especially  that  coming  along  a  cranial  nerve,  quickly  affects  the 
rhythm  in  any  viscus.  In  like  manner  irritation  from  diseased  generative 
organs  may  reach  the  heart  by  first  going  to  the  abdominal  brain  and  then 
through  the  splanchnics  to  the  pneumogastrics  and  to  the  heart. 

The  result  is  that  the  heart  is  disturbed  in  its  rhythm.  It  palpitates,  it 
beats  irregularly.  Who  has  not  seen  this  in  female  diseases?  I  think 
palpitation  is  most  manifest  at  the  menopause.  In  pregnancy  the  heart 
prepares  for  the  emergency  by  thickening  its  walls  and  is  generally  no  worse 
for  undergoing  the  extra  work  incident  to  gestation.  But  let  the  heart  meet  a 
myoma,  which  is  continually  emitting  irregular  reflections  to  it,  and  disturb- 
ing its  rhythm,  and  sooner  or  later  it  is  weakened  and  degenerated.     The  heart 


GENERAL   CONSIDERATIONS  1,1 

rests  and  repairs  itself  duing  part  of  the  rhythm,  but  irregular  reflections 
from  pelvic  diseases  do  not  allow  it  sufficient  rest.  Fatty  degeneration  or 
malnutrition  results'. 

The  heart  palpitates  at  the  menopause  because  the  accumulated  ener- 
gies of  the  abdominal  brain  find  an  easy  outlet  through  the  splanchnics  and 
pneumogastrics.  The  menopause  often  requires  several  years  for  its  com- 
pletion, so  the  abdominal  brain  can  get  accustomed  to  controlling  and  distrib- 
uting the  accumulated  energies  which  were  once  expended  in  the  menstrual 
rhythm.  The  trouble  is  that  its  accumulated  but  irregular  energies  are  apt 
to  dash  pell  mell  over  some  single  plexus  to  some  single  viscus  and  then  dis- 
aster is  sure  to  follow  from  inability  to  resist.  If  the  accumulated  energies 
were  evenly  distributed,  but  little  visceral  rhythm  would  be  disturbed. 

I  know  of  no  organ  so  manifestly  affected  in  the  menopause  as  the  heart; 
perhaps  for  the  very  reason  that  the  sympathetic  nerves  chiefly  accompany 
the  blood-vessels.  Hence,  when  some  portion  of  the  sympathetic  system  is 
disturbed,  it  is  apt  to  affect  the  nearest  structures,  which  are  those  of  the  vas- 
cular apparatus,  the  chief   portion  of  which  is  the  heart. 

The  same  kind  of  reasoning  is  applicable  to  the  spleen.  Diseased  gener- 
ative organs  reflect  their  irritation  to  the  abdominal  brain  and  then  to  the 
spleen.  Irritation  always  proceeds  irregularly,  and  so  it  would  disturb  the 
rhythm  of  the  spleen,  and  thus  create  malnutrition.  The  spleen  goes 
through  a  rhythm  just  as  do  other  viscera.  The  spleen  is  no  doubt  the  chief 
organ  concerned  in  pigmentation.  Jastrowitz,  of  Russia,  first  taught  that 
the  spleen  was  concerned  in  deposit  of  pigment ;  for  he  found  that  by  severing 
the  nerves  which  pass  to  the  spleen  on  its  vessels,  in  dogs,  irregular  pigmen- 
tation followed.  Every  gynecologist  knows  that  pigmentation  of  the  skin 
is  common  at  the  menopause,  in  pregnancy  and  at  puberty,  i.  e.,  when  the 
sympathetic  nerves  are  more  or  less  disturbed.  Of  course  little  doubt 
exists  that  the  liver  has  something  to  do  with  the  deposit  of  pigment,  as  may 
be  noted  in  malaria,  which  exercises  its  brunt  on  the  liver.  Hence,  the  dis- 
turbed rhythm  of  the  spleen  in  uterine  disturbances  manifests  itself  by  pig- 
mentary deposit. 

In  disease  of  the  uterus  it  is  quite  easy  to  note  that  the  rhythm  of  the 
bladder  is  disturbed.  It  is  not  because  the  fundus  of  the  uterus  rests  on  the 
fundus  of  the  bladder,  but  because  the  automatic  vesical  plexus  is  irritated. 
The  neck  is  dragged  or  pressed  and  the  nervous  mechanism  suffers. 

Similar  explanations  might  be  made  relative  to  the  lungs,  kidneys, 
pancreas  and  ovaries ;  but  I  think  sufficient  has  been  said  to  show  that  each 
viscus  has  its  automatic  peripheral  ganglia,  that  each  viscus  executes  a 
rhythm,  and  that  the  diseased  generative  organs  may  disturb  the  rhythm  of 
any  viscus  by  reflex  irritation  through  the  abdominal  brain. 

The  peripheral  nerve  supply  to  the  genitals  is  vast,  and  no  organ  can 
raise  such  nerve  storms  as  the  generative.  They  are  intimately  and  intensely 
connected  with  all  nerve  centers,  but  especially  those  of  the  sympathetic. 
How  often  does  one  see  strong  men  faint  from  the  simple  introduction  of 
the  sound  into  the  urethra?     The  vast  peripheral  nervous  apparatus  ending 


Fig.  50.  This  cut  represents  an  X-ray  of  the  ductus 
pancreaticus  with  part  of  the  ductus  bilis.  Four 
hepatic  calculi  are  at  B,  one  at  C,  one  at  D.  Each 
branch  of  the  ducts  are  ensheathed  by  an  anas- 
tomosed, fenestrated  meshwork  of  vaso-motor 
nerves  which  allows  an  estimate  of  the  amount  of 
vaso-motor  nerves  supplying  the  pancreas. 


Fig.  50.     DUCTUS  PANCREATICUS  WITH   PART  OF  THE  DUCTUS  BILIS 


GENERAL   CONSIDERATIONS  183 

in  the  urethra  is  disturbed,  and  this  nerve  storm  which  sweeps  up  the  hypo- 
gastric plexus  spends  sufficient  power  on  the  heart  alone  to  cause  faintness. 
Of  course  it  spends  a  relatively  large  amount  on  every  other  viscus.  Note 
how  pale  the  man  becomes.  The  storm  dwells  with  equal  force  on  the  whole 
skin  surface.  Of  all  viscera  the  genitals  are  most  intimately  and  closely 
connected  with  the  nerve  centers,  both  anatomic  and  physiologic,  for  the 
sexual  instinct  predominates  in  all  races  of  mammals.  From  the  very 
physiologic  and  anatomic  nature  of  the  reproductive  organs  they  demand  a 
close  and  intimate  nervous  connection  with  the  great  centers,  and  hence  no 
storms  affect  adjacent  and  distant  viceras  like  those  arising  in  the  extensive 
genital  nerve  periphery. 

Cold  Hands  and  Feet  in  Women. — Every  gynecologist  has  witnessed  cold 
extremities  in  women  with  diseased  generative  organs.  In  this  case  we  must 
look  to  the  great  dominating  vaso-motor  center,  situated  in  the  medulla 
oblongata.  Secondary  vaso-motor  centers  also  appear  to  exist  along  the 
main  length  of  the  spinal  cord.  The  vaso-motor  centers  are  reached  (a) 
through  the  pneumogastrics,  especially  by  irritation  coming  from  the  abdomi- 
nal brain;  (b)  by  the  lateral  chain  of  the  sympathetic  which  is  prone  to  emit 
its  irritations  along  the  brachial  plexus,  or  the  sacral  plexus,  or  the  lumbar 
plexus.  No  doubt  the  irritations  are  emitted  along  each  intercostal  nerve, 
but  vaso-motor  contractions  are  more  manifest  in  the  extremities.  In  vaso- 
motor contractions  the  skin  is  always  most  blanched  at  the  extremities,  as 
the  hands  or  feet.  When  the  generative  organs  are  diseased,  the  irritation 
goes  to  the  vaso-motor  centers  in  the  medulla  and  cord  by  two  routes: 

1.  It  travels  over  the  ovarian  and  hypogastric  plexuses  of  nerves  to  the 
abdominal  brain.  Then  it  is  reorganized  and  sent  along  the  pneumogastrics 
to  the  dominating  vaso-motor  center  in  the  medulla,  whence  it  is  reflected 
over  the  whole  body,  especially  to  the  small  vessels  at  the  extremities,  on 
which  it  is  the  most  effective  in  blanching  white  the  skin  and  cooling  the 
hands  and  feet. 

2.  It  can  also  travel  on  the  lateral  chain  from  the  coccyx,  especially  by 
way  of  the  hypogastric  plexus.  I  found  in  dissection  of  cadavers  (especially 
female)  that  the  lumbar  lateral  chain  of  ganglia  were  strongly  and  liberally 
connected  with  the  hypogastric  plexus  by  large,  thick  nerves.  Hence,  the 
irritation  from  the  generative  organs  will  go  up  the  hypogastric  plexus  and 
be  deflected  to  the  lumbar  lateral  chain  and  pass  both  to  the  spinal  cord  and 
medulla.  Then  the  vaso-motor  centers  in  the  medulla  and  cord  reflect  their 
irritations  to  the  whole  body,  but  especially  to  the  extremities.  So  that 
irritations  from  the  generative  organs  reach  the  vaso-motor  centers  in  the 
medulla  and  spinal  cord  by  two  routes:  (a)  by  the  pneumogastrics  from 
the  abdominal  brain,  and  (b)  by  the  lateral  chain  of  ganglia.  The  result 
after  following  both  routes  is  similar,  viz.,  paling  and  cooling  of  the  skin, 
especially  of  the  extremities.  Physiologists  have  proved  that  the  most  power- 
ful vaso-motor  constrictions  exist  in  the  hands  and  feet.  The  conclusions  are 
the  same  as  those  discussed  in  the  viscera.  The  end  of  the  whole  matter 
in   malnutrition,  for  the  arterioles  and   capillaries  have  been   disturbed  in 


184  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

their  rhythm.  The  vascular  rhythm  exists,  but  it  has  not  been  determined 
as  to  time.  But  when  a  large  area  of  skin  (tissue)  is  depleted  of  nourishing 
blood  for  a  considerable  time,  malnutrition  is  sure  to  result.  The  cause  and 
effect  in  the  woman  are  definite.  The  irritation  starts  in  the  generative 
organs  and  travels  by  definite  routes  to  end  in  influencing  the  sympathetic 
nerves  to  contract  the  vessels  which  the}-  surround.  I  have  such  women  in 
my  practice  continually.  Yaso-motor  effects  on  the  extremities  are  generally 
a  remote  disturbance  of  chronic  pelvic  disease.  The  irritation  of  almost  any 
viscus  which  will  effectually  disturb  the  abdominal  brain  is  liable  to  cause 
vaso-motor  constrictions.  It  is  mainly  from  the  generative  organs  in  the 
female.  By  carefully  studying  patients  one  can  see  the  immediate  and 
remote  effects  of  pelvic  disease.  The  immediate  effect  may  be  observed 
to  be  from  the  localized,  tangible,  gross  pathology.  It  may  be  pressure 
troubles,  septic  troubles  or  otherwise.  But  the  remote  effect  is  through  the 
sympathetic  nerve,  or  rather  through  malnutrition.  A  slight,  unnoticed 
irritable  focus  begins  in  the  pelvis  (it  may  be  endometritis).  Months 
and  years  go  on.  Irritations  accumulate  in  the  abdominal  brain  and  may 
radiate  on  all  its  various  plexuses.  Nutrition  is  insidiously  impaired  through 
the  months  and  years,  unbalanced  reflexes  gather  in  the  abdominal  brain, 
which,  in  turn,  disturb  the  normal  functional  rhythm  of  viscera.  Ac- 
cumulated energies,  begotten  of  long  continued  pelvic  disease,  are  not 
controlled  by  the  abdominal  brain,  but  irregular,  stormy  forces  are 
emitted  over  the  plexuses  to  the  viscera,  which  unbalances  their  rhythm 
and  ruins  their  nutrition.  The  woman  with  genital  disease  becomes  an 
object  of  wretched  despair  and  a  miserable  invalid.  The  days  of  her  life 
are  passed  between  pain  and  sadness.  Our  amateur  operative  gynecologist 
has  forgotten  that  all  her  troubles  started  from  a  lacerated  cervix  or  endome- 
tritis five  years  ago.  He  is  sure  to  extirpate  her  ovaries,  if  he  can,  and  lo! 
how  disappointed  he  is  if  she  does  not  get  well  in  a  month!  Such  a  woman 
will  not  get  well  for  long  periods.  The  only  benefit  of  extirpating  the 
appendages  was  that  she  was  compelled  to  lie  still  for  a  month — a  dear 
method  of  purchasing  a  few  weeks'  rest.  The  proper  method  to  follow  in 
this  numerous  class  of  women  is  to  hunt  for  the  old  cause  and  remove  it,  and 
then  gradually  nourish  the  woman  back  to  normal  health.  Such  women  are 
called  hysterical,  but  there  is  generally  some  pelvic  pathology  that  precedes 
hysteria  before  the  abdominal  brain  suffers  derangement. 

Space  forbids  any  discussion  as  to  the  dependence  or  independence  of 
the  sympathetic  nerve  in  regard  to  the  cerebrospinal  system.  Yet  we  may 
assert  that  the  sympathetic  is  independent  to  a  certain  degree.  Babies  have 
been  born  at  full  term  with  no  cerebrospinal  axis.  The  heart  will  beat 
some  time  after  death.  I  have  often  noted  the  intestines  performing  peri- 
stalsis more  than  an  hour  after  death.  I  have  watched  the  uterus  going 
through  its  rhythm  in  slaughtered  cows  an  hour  and  a  half  after  death.  The 
independence  of  the  sympathetic  is  seen  in  vaso-motor  neuroses  of  the 
extremities.  The  tone  of  vessels  is  maintained  by  the  sympathetic.  The 
sympathetic  controls  secretion.     If  the  brain   and  spinal  cord  of  a  frog  are 


GENERAL   COXSIDERATIOXS 


LS5 


removed,  his  skin  will  show  pigmentation.  The  viscera  have  involuntary 
movements  and  are  out  of  will  control, — are  excluded  from  the  mental 
sphere.  But,  like  the  watch,  which  requires  every  cog  and  wheel  to  keep 
time,  so  the  sympathetic  needs  the  cerebrospinal  to  maintain  the  balance 
of  life. 

A  few  general  ideas  of  the  sympathetic  nerve  may  be  of  interest.  The 
rhythm  of  the  viscera,  due  to  the  abdominal  brain,  will,  no  doubt,  adequately 
explain  the  axial  rotation  of  abdominal  tumors.  The  emptying  and  filling 
of  hollow  viscera  in  their  continual  rhythm  is  apt  to  rotate  adjacent  tumors 


CORROSION  ANATOMY 

Fig.  51.  This  specimen  of  corrosion  anatomy  of  the  uterus,  oviducts  and  ovary  of  a 
newborn  infant  represents  the  blood  supply  of  the  genitals  in  a  quiescent  state.  Each 
arterial  branch  is  ensheathed  by  an  anastomosed,  nodular,  fenestrated  meshwork  of 
vaso-motor  nerves.  This  method  enables  one  to  estimate  the  quantity  of  nerve  supply  to  the 
uterus. 


with  narrow  styles.  Narrow  pedicles  are,  of  course,  more  likely  to  rotate 
than  thick  ones.  It  is  a  curious  fact  that  when  a  woman  possesses  more  than 
one  tumor  in  the  abdomen,  there  is  more  danger  of  axial  rotation.  A  preg- 
nant uterus  or  tumor  doubles  the  danger  of  the  twisting  of  the  tumor  on  its 
axis.  The  axial  rotation  of  a  tumor  is,  no  doubt,  enhanced  by  the  sudden 
emptying  of  the  uterus,  and  its  change  of  location  at  delivery.  But  the  main 
point  in  the  matter  is  visceral  rhythm,  e.  g.,  of  the  intestines  and  bladder. 
It  is  estimated  that  10  per  cent  of  abdominal  tumors  rotate  on  their  axes. 
The  reflexes  of  the  abdominal  brain  and  sympathetic  ganglia  are  very 
numerous. 


186  THE  ABDOMINAL  AND  PELVIC  BRAIN 

A  blow  on  the  solar  plexus  causes  syncope  by  reflex  action  on  the  heart. 
The  vagus  (right)  compels  the  heart  to  beat  soberly,  and  two-thirds  of  the 
right  vagus  goes  also  into  the  abdominal  brain.  But  the  cervical  sympathetic 
rules  the  heart  in  its  rapidity  and  regularity.  The  vomiting  on  the  passage 
of  gall-stones,  or  renal  calculi,  or  that  of  pregnancy,  shows  the  abdominal 
brain  to  be  a  great  reflex  center  and  place  of  reorganization  of  forces.  Notice 
the  changed  pulse  in  peritonitis,  and  the  tremendous  collapse  in  intestinal 
perforation,  due  to  disturbed  circulation.  Watch  the  shock  after  colotomy, 
due  to  trauma  on  the  peritoneum.  The  peritoneum  is  mainly  supplied  by 
sympathetic  nerves,  so  it  acts  through  the  solar  plexus.  It  is  easy  to  see  how 
nerve  storms  shock  the  heart  from  peritoneal  manipulation.  I  have  noted 
depression  of  the  heart.  The  peripheral  arteries  contract  and  the  heart 
cannot  drive  the  blood  home.  It  is  easily  seen  that  in  the  abdominal  brain 
and  cervical  sympathetic,  the  great  regions  of  reflex  action  play  a  great  role 
in  neuroses  and  all  emotional  phenomena.  When  we  feel  fear  or  fright,  the 
effect  is  noticeable  in  the  solar  plexus,  which  lies  behind  the  stomach. 
Sorrow  and  sadness  are,  frequently,  first  felt  in  the  abdominal  brain.  The 
good-hearted  David  said  that  he  "yearned  for  the  young  man  in  his  bowels." 
His  is  only  a  common  experience  that  the  abdominal  brain  plays  a  role  in 
emotional  and  neurotic  phenomena  because  of  its  capacity  for  reflex  action. 


CHAPTER  XV. 

THE  INDEPENDENCE  OF  THE  SYMPATHETIC  NERVE. 

The  function  of  thetractus  intestinalis  is  sensation,  rhythm  (pcrsistalsis),  secre- 
tion   and  absorption.     It    has   an    impart   and  export    service. 
".I    zcant  of     individuality    is  the     }nost     dangerous     sign    in    modern     civiliza- 
tion.".—John    Stuart    Mill. 

It  may  aid  in  comprehending  the  structure  and  function  of  the  sympa- 
thetic nerve,  and  in  concluding  the  discussion  in  regard  to  its  independence, 
to  arrange  in  short,  concise  propositions  a  number  of  observations  which  will 
show  that  the  sympathetic  nerve  has  a  large  degree  of  independence. 

1.  The  independence  of  the  sympathetic  system  is  impressively  shown 
in  the  distinct  rhythmical  action  of  the  heart  for  some  time  after  being  re- 
moved from  the  body.     This  can  be  best  demonstrated  in  the  frog  and  turtle. 

2.  The  peristaltic  and  vermicular  motions  of  the  intestines  after  death 
significantly  point  to  the  independence  of  the  sympathetic  nervous  system. 
The  intestines  of  a  dog  will  continue  in  peristalsis  for  two  hours  after  death 
if  the  room  temperature  be  100  degrees  Fahrenheit. 

3.  The  fetus  has  been  born  at  or  about  term  without  a  trace  of  brain  or 
cord.  This  shows  that  nutrition,  growth,  secretion,  absorption  and  circula- 
tion were  conducted  alone  by  the  sympathetic — one  of  the  strongest  demon- 
strations of  its  independence. 

4.  Experiment  has  shown  that  nutrition  (which  means  life's  function) 
may  be  carried  on  after  complete  destruction  of  the  cerebrospinal  centers. 

5.  Nourishment  without  the  cerebrospinal  center  would  indicate  that 
the  arteries  (blood-vessels)  are  under  the  control  of  the  sympathetic  system. 
Goltz  goes  so  far  as  to  say  that  the  tone  of  the  arteries  is  maintained  by  local 
centers  situated  in  their  own  immediate  vicinity. 

6.  The  manifestations  of  blushing,  local  congestions  and  eruptions 
would  tend  to  show  that  the  blood  acts  reflexly  on  the  vessels,  affecting  the 
vaso-dilators  or  the  vaso-constrictors.  The  white  line  (followed  rapidly  by  a 
red  one)  on  stroking  the  skin  with  the  finger,  as  in  scarlet  fever,  indicates  that 
the  vessels  possess  local  nerve  centers  of  control.  The  trauma  produced  on 
the  vascular  centers  by  stroking  the  skin  first  irritates  the  vaso-constrictors, 
and  paleness  results  from  constriction  of  the  vessels.  The  secondary  result 
of  the  trauma  on  the  vaso-constrictor  is  that  they  are  paralyzed,  and  then  the 
vaso-dilators  dominate  with  a  resulting  red  line. 

Bernard,  in  1851,  was  the  first  to  show  conclusively  that  the  sympathetics 
controlled  the  caliber  of  the  blood-vessels.  Any  one  who  has  long  practiced 
medicine,  observing  the  heart  and  the  aorta,  will  be  able  to  note  that  the 
heart  itself,  and  the  aorta,  have  seasons  of  dilatation  and  contraction.  For 
example,  in  many  spare,  neurotic  women  it  is  common  to  note  that  the  aorta 
has  periodic  times  of  powerful  rhythms  or  beatings.     With  the  hand  on  the 

187 


188  THE  ABDOMINAL  AXD  PELVIC  BRAIX 

abdomen  the  inexperienced  announces  a  growing  aneurism  of  the  abdominal 
aorta.  The  aorta  beats  with  such  tremendous  force  that  the  patient  will  call 
the  physician's  attention  to  the  phenomenon.  A  few  hours  subsequently  its 
rhythm  will  be  quieted  and  in  a  normal  state.  This  phenomenon  of  the 
excessive  abdominal  aortic  rhythm,  or  beat,  is  perhaps  due  to  the  excitation 
of  the  local  nerve  centers  which  control  its  caliber;  for  I  could  scarcely 
detect  the  excessive  arterial  beat  in  another  portion  of  the  body,  as  the  wrist. 
At  such  times  the  heart  acts  slightly  differently  from  normal.  It  is  a  little 
more  noisy  and  appears  as  if  it  were  dilated  more  than  usual.  Another 
phenomenon  in  regard  to  nerve  centers  which  control  vascular  tone  (contrac- 
tion and  dilatation)  may  be  observed  in  the  heart.  By  careful  watching 
of  the  heart  of  an  individual,  one  may  note  that  the  heart  changes  at  times  in 
both  its  method  of  beat  and  its  size.  Occasionally  the  heart  will  dilate,  beat 
with  more  noise,  continue  so  for  some  hours,  and  then  subside  to  its  natural 
state.  This  phenomenon,  as  well  as  that  of  aortic  dilatation  and  contraction, 
is  doubtless  due  to  the  controlling  sympathetic  nerve  centers  localized  in  the 
substance  or  immediate  vicinity  of  the  heart  and  aorta.  The  heart,  like  a 
blood-vessel  under  the  controlling  vascular  nerve  centers  of  the  sympathetic, 
dilates  and  contracts  and  varies  its  rhythm  still  more  within  wide  ranges.  I 
have  never  seen  this  periodic  dilatation  noted  in  an}'  book.  Practically 
nothing  is  to  be  found  in  books  concerning  this  peculiar  periodic  dilatation 
and  vigorous  beating  of  the  abdominal  aorta. 

7.  The  abdominal  brain  (the  solar  plexus,  the  semilunar  ganglion)  may 
be  viewed  as  a  gigantic  vaso-motor  center  for  the  abdominal  viscera.  The 
dilatation  and  contraction  of  the  heart  and  aorta,  with  the  periodic  varying 
of  the  vigor  of  their  rhythm  (without  recognizable  disease),  may  be  referred 
to  this  king  of  vaso-motor  centers — the  abdominal  brain.  In  the  progress  of 
life's  vascular  phenomena  the  abdominal  brain,  as  a  vaso-motor  center, 
exercises  very  dominant  and  quite  independent  prerogatives. 

8.  The  dependence  and  independence  of  the  cerebrospinal  and  sympa- 
thetic system  of  nerves  may  be  compared  to  the  state  and  federal  government, 
or  the  municipal  and  state  government.  The  former  run  in  harmony,  when 
friction  does  not  arise.  Yet  the  state  lives  quite  a  distinct  individual  life, 
quite  independent  from  the  federal  government.  The  life  of  each  is  depend- 
ent, however,  on  the  other.  The  internal  life  of  each  (as  of  the  sympathetic 
nerve)  maintains  itself. 

9.  The  sympathetic  system  alone  would  maintain  life  (sensation,  per- 
istalsis, absorption,  secretion),  especially  in  each  viscus,  but  the  cerebrospinal 
system  coordinates  the  various  viscera  as  a  whole  into  a  definite  purpose  or 
plan.  The  cerebrospinal  system  is  an  executive  to  suggest  or  organize  the 
efforts  of  each  system,  ruled  by  the  sympathetic,  to  combine  for  a  common 
object — the  continuation  of  an  organized  subject.  The  efforts  of  the  circu- 
latory system  would  be  useless  were  they  not  combined  with  all  the  efforts 
of  the  digestive  system,  as  well  as  those  of  the  genito-urinary  system.  The 
cerebrospinal  system  simply  coordinates  the  various  independent  systems 
(circulatory,  digestive  and  genito-urinary)  into  a  unit  of  life. 


INDEPENDENCE  OF  THE   VASO-MOTOR  NERVE  1*9 

10.  The  phenomena  of  vasoneurosis  of  the  extremities  would  indicate 
a  great  degree  of  independence  of  the  sympathetic  nerve. 

11.  The  ordered  richness  of  the  sympathetic  nerves  in  ganglion  cells, 
similar  to  the  cerebrospinal  ganglia,  would  tend  to  demonstrate  its 
dependence. 

1:2.  The  accumulation  or  aggregation  of  ganglion  cells  in  the  sympa- 
thetic should  be  sufficient  argument  for  considering  them  as  small  brains- 
nerve  centers  of  life's  action. 

13.  The  independence  of  the  sympathetic  nerve  may  be  observed  in  the 
fact  that  as  it  departs  more  widely  from  the  cerebrospinal  it  increases  in 
elements.  Increased  distribution  shows  increased  aggregation  of  ganglion 
cells,  e.  g.,  the  Meissner-Billroth  and  Auerbach's  plexuses  in  the  small 
intestines. 

14.  There  is  a  partial  necessity  that  the  sympathetic  be  relatively 
independent,  at  least  be  out  of  the  control  of  the  cerebral  center.  The 
viscera  being  necessitated  to  be  in  constant  activity,  constant  rhythm,  should 
be  beyond  the  control  of  the  will,  so  that  man  cannot  speculate  on  his 
viscera.  The  intellect  cannot  disturb  the  function  of  the  viscera.  The 
actions  of  the  sympathetic  ganglion  are  beyond  the  power  of  the  will. 

15.  A  stubborn  opponent  of  the  independence  of  the  sympathetic  nerve 
(Hermann)  freely  acknowledged  that  automatic  and  reflex  coordinate  move- 
ments and  secretions  can  be  the  indication  of  the  sympathetic  ganglion  cells 
quite  independent  of  the  cerebrospinal  symptoms. 

16.  A  significant  partial  independence  of  the  sympathetic  may  be 
observed  in  peritonitis.  The  reflex  irritation  induced  by  the  peritonitis  causes 
extreme  vaso-motor  contraction  in  the  skin.  The  skin  becomes  waxy  pale, 
the  blood  is  forced  out  of  the  skin  by  contraction  of  the  vessels  and  the  patient 
dies  gradually  from  circumference  to  center.  The  heart  at  first  attempts  to 
work  more  vigorously  to  send  the  blood  to  the  skin  vessels,  but  the  harder 
the  heart  works  in  sending  the  waste-laden  irritating  blood  to  the  vessels,  the 
more  they  contract,  and  gradually  death  approaches  the  heart.  The  inde- 
pendence of  the  grip  of  the  sympathetic  nerve  is  seen  in  the  gradual  death 
of  the  patient,  beginning  in  the  skin  capillaries  and  ending  at  the  heart.  It 
is  a  good  illustration  of  the  fact  that  irritation  of  the  sympathetic  nerves  may 
be  sufficient  to  force  all  blood  out  of  a  part  even  to  its  death. 

17.  Vulpian  severed  the  sciatic  and  brachial  plexuses  and  waited  until 
the  pulp  of  the  animal's  corresponding  paws  became  pale.  Now,  by  irritating 
the  pulp  of  the  paws  a  local  congestion  could  be  produced.  Hence  reflex 
irritation  of  vaso-motor  nerves  can  be  limited  to  the  particular  organ  or  tissue 
supplied,  showing  a  considerable  degree  of  independence. 

18.  It  has  been  suggested  by  Fox  that  myxedema  is  associated  with  the 
independence  of  the  sympathetic. 

19.  Compression  or  macroscopial  injuries  of  the  cervical  portion  of  the 
sympathetic  produces  such  a  marked  physiologic  phenomenon  that  it  demon- 
strates in  itself  a  considerable  degree  of  independence  of  the  sympathetic. 
The  manifestation  of  compression  or  injury  of  the  cervical  sympathetic  is 


190  THE  ABDOMINAL  AND  PELVIC  BRAIN 

that  of  the  irritation  or  paralysis.  Trauma  of  the  cervical  sympathetic  shows 
marked  independent  functional  disturbances.  Exophthalmic  goiter  is  con- 
sidered, even  by  the  skeptical  Eulenberg  and  Guttmann,  as  a  paralysis  of 
the  cervical  sympathetic.  If  the  latter  can  produce  such  vast  changes,  and 
such  a  dreadful  disease,  how  great  must  be  the  influence  of  the  abdominal 
brain  in  its  independence.  In  exophthalmic  goiter  the  independence  of  the 
sympathetic  seems  dominant,  for  of  the  great  triumvirate  in  that  disease — 
cardiac  palpitation,  protrusion  of  the  eyeball  and  enlargement  of  the  thyroid 
gland — the  cardiac  palpitation  seldom  fails.  Few  experimenters  or 
observers  fail  to  connect  the  cardiac  disturbance  with  the  cervical  sympa- 
thetic, showing  how  dominating  it  is  in  this  case. 

20.  The  gastro-intestinal  secretions  appear  to  be  carried  on  automatic- 
ally by  the  Meissner-Billroth  (aided  by  the  Auerbach)  plexuses  of  nerves, 
which  are  sympathetic  ganglia — automatic  visceral  ganglia.  The  automatic 
visceral,  hepatic,  renal,  gastro-intestinal  and  menstrual  ganglia,  all  show  a 
marked  degree  of  independence.  They  produce  rhythm  in  the  viscera — 
activity  and  repose.  Undisturbed,  they  rule  secretion  harmoniously,  but 
disturbed  anatomic  visceral  ganglia  induce  'a)  excessive  secretion,  (b) 
deficient  secretion  and  (c)  disproportionate  secretion.  The  last  isthe  most 
detrimental,  for  it  creates  fermentation  and  unbalances  nutrition. 

21.  The  independence  of  the  automatic  visceral  ganglia  of  the  sympa- 
thetic may  be  noted  in  the  idea  that  if  one  viscus  becomes  diseased  it  may 
disturb  all  the  others  by  reflex  action. 

22.  If  one  viscus  becomes  diseased  the  next  to  become  diseased  is  the 
one  connected  with  the  diseased  viscus  by  the  greatest  number  of  nerve 
strands.  If  the  uterus  becomes  diseased  the  next  viscus  in  order  is  generally 
the  stomach.  However,  this  is  probably  due  to  the  fact  that  the  disturbed 
stomach  functions  are  easily  observed. 

23.  The  abdominal  brain  is  a  center  of  organization  for  impressions 
received  from  distal  viscera.  It  is  a  gigantic  vaso-motor  center  for  the 
abdominal  vascular  system.  The  abdominal  brain  demonstrates  its  inde- 
pendence by  its  definite  method  of  reorganizing  reflex  actions.  When  an 
abdominal  viscus  is  mildly  ill,  the  abdominal  brain  reorganizes  the  reflex 
impressions  and  transmits  them  mildly  to  adjacent  viscera.  But  if  a  viscus 
is  severely  and  especially  chronically  ill,  the  abdominal  brain  reorganizes  the 
reflexes  and  transmits  them  violenth*  to  the  adjacent  viscera,  according  to 
the  degree  of  illness.  Also  the  reflexes  reorganized  in  the  abdominal  brain 
are  transmitted  outward  to  the  viscera  with  greatest  force  on  the  lines  of 
least  resistance,  which  means  that  the  nerve  forces  travel  on  the  plexuses  the 
best  where  there  are  the  greatest  number  of  nerve  strands. 

24.  The  independence  of  the  sympathetic  nerve  may  be  observed  in  the 
phenomenon  of  sleep.  It  never  ceases  action  nor  sleeps,  while  the  cerebro- 
spinal is  in  abeyance  for  about  one-third  of  our  life. 

25.  E.  L.  Fox  reports  two  cases  of  compression  myelitis  in  the  cervical 
portion  of  the  cord  unattended  by  any  oculopupillary  or  vaso-motor  paralysis. 
This  would  tend  to  show  the  independence  of  the  sympathetic,  especially  the 
cervical  sympathetic. 


IX DEPENDENCE   OF   THE  A  E  Rl ' I  \V  / '.  [SUM OTO Rl  US         m 

26.  Experimenters  report  that  irritation  of  some  portion  of  the  cervical 
sympathetic  will  produce  secretions  from  the  parotid  and  submaxillary  glands. 

27.  Fox  asserts  that  irritation  of  the  peripheral  end  of  the  cervical 
sympathetic  will  cause  protrusion  of  the  eyeball;  sedation  will  cause  sinking 
of  the  eyeball,  and  a  slight  flattening  of  the  cornea.  We  know  that  in  the 
lids  are  sets  of  smooth,  muscular  fibers  innervated  by  the  sympathetic,  and 
by  contraction  of  these  the  lids  are  opened  and  so  the  eyeball  is  uncovered. 

28.  In  general  it  may  be  said  that  the  sympathetic  presides  over 
involuntary  movements,  nutrition  and  secretion,  holds  an  important  influence 
over  temperature  and  vaso-motor  action,  and  is  endowed  with  a  dull 
sensibility. 

29.  Experiments  show  that  after  destruction  of  the  medulla  oblongata 
and  brain  of  the  frog  irritation  will  cause  congestion  of  the  limbs. 

30.  The  occurrence  of  pigmentation  in  the  skin  of  the  frog,  after 
destruction  of  the  cerebrospinal  axis,  shows  the  independence  of  the  sym- 
pathetic. 

31.  Each  histologic  unit  has  its  own  nervous  system,  which  is  sufficient 
for  it  within  certain  limits. 

It  may  be  said  that  the  object  of  the  lateral  chain  of  the  sympathetic  is 
to  make  known  the  great  ganglionic  system  to  the  cerebrospinal  system. 

32.  The  ganglia  of  the  uterus  (sympathetic)  are  independent  centers  for 
reflex  action.  That  it  can  act  independently  may  be  shown  by  the  repulsion 
of  a  child  after  the  death  of  the  mother.  It  has  a  powerful  reflex  action  on 
the  heart.  It  is  a  great  independent  sympathetic  ganglion.  Associated 
anatomically  with  the  abdominal  brain  are  the  following  plexuses:  (a)  the 
diaphragmatic;  (b)  the  suprarenal;  (c)  the  renal;  (d)  the  spermatic;  (e)  the 
superior  mesenteric,  which  intimately  connect  it  with  all  the  abdominal 
viscera. 

33.  The  expulsion  of  feces  per  rectum  after  death  of  the  patinet  shows 
that  the  sympathetic  ganglia  of  the  bowels  are  independent  centers  for  reflex 
action. 

34.  Pigmentation  of  the  skin  in  the  frog,  after  destruction  of  the  cere- 
brospinal, demonstrates  the  independence  of  the  sympathetic. 

35.  The  abdominal  brain  is  a  great  reflex  center.  Vaso-motor  centers 
are  organizing  centers,  and  preside  over  the  coordination  of  the  visceral 
rhythm.  The  abdominal  brain  is  a  ganglion  of  far  reaching  significance.  It 
has  many  connections  with  viscera  and  possesses  vast  influence  over  the 
circulation.     It  presides  closely  over  the  secretion  of  the  abdominal  organs. 

36.  That  the  sympathetic  is  the  only  nervous  system  belonging  to  some 
of  the  lower  animals  is  open  to  doubt ;  for  if  that  were  the  case,  no  argument 
would  be  required  to  demonstrate  the  independence  of  the  sympathetic. 
The  distinction  of  the  cerebrospinal  and  sympathetic  as  to  sleep  or  repose, 
since  it  cannot  be  proven,  must  be  dropped.  In  any  argument  we  must 
admit  the  very  intimate  and  mutual  dependence  of  the  sympathetic  and  cere- 
brospinal nerves  on  each  other. 

37.  The  essential  feature  of  the  pathology  of  the  sympathetic,  and  also 


192  THE  ABDOMINAL  AXD  PELVIC  BRA  IX 

one  which  tends  to  show  its  independence,  is  that  the  irritation  in  one  organ 
may  be  reflected  through  a  sympathetic  ganglion  and  thus  disturb  the  balance 
of  the  viscera.  The  best,  most  common  and  convincing  example  is  irritation 
of  the  cervico-uterine  ganglia,  which  is  directly  reflected  to  the  abdominal 
brain,  where  the  irritation  is  reorganized  and  sent  to  all  the  nerve  plexuses. 
38.  The  degree  of  independence  of  the  sympathetic  nerve  must  be 
worked  out  on  the  lines  of  experiment  and  observation  of  the  effect  of  disease 
on  its  different  parts.  To  what  degree  is  the  abdominal  brain  a  center  for 
the  reorganization  of  forces;  how  does  it  modify  and  transmit  receptions?  How 
supreme  is  it  over  the  visceral  ganglia  or  does  it  coordinate  their  action  to  a 
definite  plan?  Does  it  enhance  or  prohibit  their  action?  Is  the  abdominal 
brain  a  reflex  arc  for  nerve  forces,  passing  from  one  organ  to  another?  In 
other  words,  will  one  diseased  organ  unbalance  all  other  organs  by  transmit- 
ting its  irritation  by  way  of  the  reorganizing  abdominal  brain? 


CHAPTER  XVI. 

ANATOMIC  AND  PHYSIOLOGIC   CONSIDERATIONS. 

The  sympathetic  rules  tin-  rhythm  (peristalsis)  of  vascular  canals  and  glandular 

ducts  of  the  body. 
"The  first  questions  to  put  to  a  zvitness  are  as  to  his  name  and  place  of  residence, 

and  his  means  of  knowledge  of  the  facts  concerning  which  he  is  expected 

to  testify." — Judge  Charles  B.  IVaite. 

After  considerable  microscopical  investigation  I  am  convinced  that  we  do 
not  know  the  whole  sympathetic  nerve,  nor  do  we  fully  know  its  distribution 
because  of  its  tenuity.  This  remark  is  made  as  evidence  gained  in  long 
microscopical  labors  on  the  peritoneum,  in  which  I  have  been  interested  for 
years.  In  the  peritoneum  we  cannot  tell  the  function  of  a  nerve  from  its 
microscopical  appearance.  We  may  assert  that  the  width  of  the  nerve 
indicates  its  length,  that  a  wide  nerve  is  a  long  nerve. 

Now  a  sympathetic  nerve  is  a  non-medullated  nerve,  i.  e.,  the  white  sub- 
stance of  Schwann  is  lacking,  at  least  it  is  not  visible  by  our  present  optical 
instruments,  or  the  present  known  reagents.  However,  it  appears  to  me  to 
be  present  in  Remak's  bands  (sympathetic  fibers),  though  in  an  exceedingly 
thin  layer.  Again,  many  nerves  in  the  peritoneum  begin  with  a  medullary 
sheath  and  end  without  one.  The  nerve  is  sheathed  for  part  of  its  course 
and  non-sheathed  for  another  part.  But  whether  we  are  to  call  a  nerve 
which  is  sheathed  in  its  whole  course  or  in  a  part  of  its  course,  a  sympathetic 
or  a  non-sympathetic,  depends  upon  whether  it  shows  a  different  function. 
In  ordinary  parlance  a  sympathetic  nerve  should  have  no  visible  sheath  of 
Schwann,  i.  e.,  no  medullary  sheath.  A  sympathetic  nerve  is  perhaps  better 
known  by  its  function  than  by  its  microscopical  appearance.  In  fact  no 
microscopist  can  decide  merely  by  the  appearance  whether  a  nerve  be  sym- 
pathetic or  non-sympathetic,  unless  he  claim  that  all  non-sheathed  nerves  are 
sympathetic.  For  one  can  trace  the  medulla  on  a  nerve  in  the  peritoneum 
for  a  long  distance  when  suddenly  it  disappears.  Should  one  meet  this  nerve 
unsheathed  in  any  portion  of  the  peritoneum,  he  could  not  decide  upon  its 
function.  At  present  we  must  discuss  the  function  and  not  the  microscopical 
structural  differences. 

One  of  the  best  places  to  study  the  sympathetic  nerves  is  in  the  peri- 
toneum of  the  kitten  (when  about  six  weeks  old).  The  reagent  best  suited 
for  practical  microscopical  work  is  as  follows:  Acetic  acid  5  parts,  gold 
chloride  1  part,  and  water  994  parts.  The  rabbit's  peritoneum  is  quite  good, 
but  not  so  good  as  the  cisterna  lymphatica  magna  of  the  frog's  peritoneum. 
Now  it  is  not  difficult  to  trace  the  gangliated  cords  lying  on  each  side  of  the 
vertebral  column.  In  spare  subjects  the  branches  running  from  the  cords 
and  ganglia  are  plainly  visible.     By  a  little  care  we  can  trace  the  branches  of 

13  193 


194 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


the  ganglia  and  cords  directly  to  the  brain  and  spinal  cord.  The  sympathetic 
system  lies  in  front  of  the  cerebrospinal,  as  a  secondary  system  enclosed  in 
a  cavity,  the  thoraco-abdominal,  just  as  the  cerebrospinal  is  enclosed  in  the 
cerebrospinal  canal.  The  sympathetic  system  is  characterized  by  having 
non-medullated  nerve  fibers.  It  frequently  has  large  round  ganglion  cells 
enclosed  in  thick  dense  capsules. 


'"''ooait**0 

ABDOMINAL  BRAIN  AND  PLEXUS  AORTICUS 

Fig.  52.    This  illustration  presents  a  limited  amount  of  sympathetic  nerves  in  outline. 
(George  Dancer  Thane). 


The  ganglion  cells  lie  scattered  over  considerable  areas,  and  are  sepa- 
rated by  dense,  thick  portions  of  connective  tissue.  The  ganglion  cells  of 
the  sympathetic  do  not  atrophy  in  early  old  age,  as  claimed  by  some,  for 
before  me  lies  a  beautiful  microscopical  section  of  the  abdominal  brain  of  a 
woman  who  died  at  about  the  age  of  72,  in  which  the  characteristic  feature  is  the 
numerous  large  ganglion  cells  ensheathed  in  thick  connective  tissue  capsules. 
It  may  be  that  in  some  cases  the  superior  cervical  ganglion  does  develop  an 


ANATOMIC    AND    PHYSIOLOGIC    CONSIDERATIONS        195 

excess  of  connective  tissue  which  crushes  out  the  delicate  ganglion  cells,  but 
such  cases  I  have  not  observed  in  the  abdominal  brain,  which  must  serve 
some  great  economic  plan  in  the  system.  The  significance  of  the  abdominal 
brain  and  sympathetic  system  must  not  be  forgotten,  as  children  are  born 
without  a  brain,  and  some  reports  note  the  absence  of  the  medulla  also.  In 
such  children  the  heart  and  viscera  have  been  kept  going  by  the  sympathetic 
system.  Dr.  W.  F.  Ball,  of  Mantua  Station,  Ohio,  reported  such  a  case 
to  me. 

The  sympathetic  nerve  is  characterized  by  accumulations  of  cells  at  cer- 
tain points,  these  being  known  as  ganglia.  In  the  abdomen  and  chest  the 
ganglia  have  a  regularity  of  location  corresponding  to  definite  segments  of 
the  body.  There  is  a  long  chain  of  such  ganglia  situated  on  each  side  of  the 
vertebral  column,  known  as  the  lateral  chain  of  sympathetic  ganglia,  and 
extending  from  the  first  cervical  to  the  last  sacral  vertebra.  Two  fine,  small 
cords  connect  the  spinal  cord  with  each  of  the  ganglia  of  the  lateral  chain, 
making  a  close  and  intimate  relation  of  the  spinal  cord  and  lateral  chain. 
The  spinal  cord  is  doubly  connected  with  the  lateral  chain.  The  medullated 
branch  passes  from  the  anterior  root  to  the  ganglia.  The  non-medullated 
root  passes  to  the  blood-vessels  of  the  cord.  The  lateral  chain  is  well  pro- 
tected by  adjacent  bony  structures  from  any  injury  or  pressure  by  viscera. 

Ventral  to  the  lateral  chain  there  are  located  three  nerve  plexuses:  one 
in  the  chest,  the  cardiac;  one  in  the  abdomen,  the  abdominal  brain;  and  one 
in  the  pelvis,  the  utero-cervical,  or  as  I  prefer  to  call  it,  the  pelvic  brain. 
The  thoarcic  and  abdominal  plexuses  are  single,  located  in  the  ventral  line 
of  the  body  and  possessed  of  a  large  amount  of  nervous  ganglia  and  cells, 
especially  the  abdominal  brain.  The  pelvic  plexus  is  double,  situated  on  each 
side  of  the  cervico-uterine  junction,  and  is  quite  a  massive  collection  of 
ganglia  and  nerve  cells.  All  three  central  plexuses,  the  thoracic,  abdominal 
and  pelvic,  are  bound  by  intimate  and  very  close  relations  with  the  lateral 
chain  of  sympathetic  ganglia.  Every  viscus  is  profusely  supplied  with  the 
sympathetic  strands,  and  the  vast  number  of  cords  and  ganglia,  like  the 
equalizers  on  a  horse  power,  hold  in  intimate  relation  all  the  viscera  in  a 
delicate  balance.  Specialists  are  beginning  to  recognize  the  wonderful 
sympathetic  balance  of  all  the  viscera,  for  when  one  gets  out  of  order  it 
untunes  the  chorus  of  the  whole.  In  fact,  if  a  viscus  in  an  adult  is  dis- 
turbed, it  is  generally  the  genitals,  and  it  soon  unbalances  the  remainder.  It 
is  easy  to  note  the  large  cords,  the  ganglia  and  the  invertebral  plexuses  of 
the  sympathetic  system,  to  note  their  distribution  and  the  relations  of  the 
ganglia  to  the  viscera  in  spare  subjects  hardened  by  alcohol.  It  is  not 
difficult  to  see,  even  in  rough,  incomplete  experiments,  that  there  is  a  certain 
independence  of  the  ganglia  distributed  to  the  viscera.  Though  the  latter 
are  seen  to  be  in  close  relationship  with  the  great  structure  of  the  sympa- 
thetic, yet  they  show  definite,  independent  action.  An  hour  after  death  one 
can  induce  the  viscera  in  a  dog  to  act  by  slight  irritation  or  stimulation. 
Perhaps  little  remains  to  be  discovered  concerning  the  arrangement  of  the 
automatic  ganglia  in  the  viscera,  or  the  structural  arrangement  of  the  cere- 


196  THE  ABDOMINAL  AND  PELVIC  BRAIN 

brospinal  and  sympathetic  systems.  But  much  remains  to  be  discovered  in 
regard  to  the  functional  relations  of  the  cerebrospinal  and  sympathetic 
systems.  Each  system  may  contain  structures  of  the  other,  or  not.  As  a 
birdseye  view  of  the  sympathetic  nervous  system  we  may  produce  the 
following: 

1.     A  series  of  distinct  ganglia  connected  by  nerve  cords,  extending  from 
the  base  of  the  skull  to  the  coccyx. 


DUCTUS  BILIS  ET  DUCTUS  PANCREATIS  ET  AORTERIA  HEPATICA 

Fig.  53.  This  illustration  represents  the  biliary  and  pancreatic  ducts  with  the  hepatic 
artery,  which  are  each  ensheathed  with  a  fenestrated  network  of  sympathetic  nerves. 

AH,  hepatic  artery;  I,  vateis  diverticulum  ;  II,  junction  of  ductus  cysticus  and  ductus 
hepaticus  ;  III,  ductus  hepaticus  ;  IV,  cholecyst  with  its  duct. 

2.  Automatic  visceral  ganglia. 

3.  A  series  of  three  centrally  located  prevertebral  plexuses,  situated  in 
the  thorax,  abdomen  and  pelvis. 

4.  A  series  of  communicating  and  distributing  nerve  fibers. 

The  above  propositions  may  be  reduced  to  three  elements,  viz.,  nerve 
fibers  and  nerve  cells,  or  ganglia  and  periphery. 

The  caudal  end  of  the  sympathetic  ends  in  a  nerve  mass  known  as  the 
ganglion  impar,  and  the  head  (frontal)  end  ceases  in  the  ganglk-n  of  Prof. 


ANATOMIC    AND    PHYSIOLOGIC    COX  SI  DURATIONS         197 

Francois  Ribes  of  Montpelier,  France  (1800-1864).  I  must  confess  that  my 
searches  for  Ribes'  ganglion  have  not  been  fully  successful. 

We  find  the  sympathetic  nervous  system  very  widely  distributed  and  it 
must  not  be  considered  improbable  to  find  sympathetic  centers  in  the  cere- 
brospinal axis.  The  seat  of  a  ganglion  may  be  anywhere  and  yet  not  partake 
of  the  adjacent  surroundings,  i.  e.,  sympathetic  ganglia  may  be  situated  in 
the  cerebrospinal  axis,  yet  not  be  an  integral  part  of  it,  particularly  as 
regards  function.  Thus  we  may  consider  the  vaso-motor  center,  the  cardiac, 
and  other  centers,  located  in  the  medulla  and  cord,  not  to  be  a  part  of  them. 

This  view  must  hold  as  a  fact,  for  blood-vessels  which  necessarily  supply 
all  parts  of  the  body,  brain  or  spinal  cord,  must  be  supplied  with  sympathetic 
nerves  to  regulate  their  caliber,  but  neither  the  nerves  nor  the  blood-vessels 
are  of  the  cord  or  medulla.  The  sweat,  heat  (flashes)  and  vaso-motor 
(flushes)  centers  are  located  in  the  medulla  and  segments  of  the  cord. 
Pathologic  states,  as  at  the  menopause,  make  all  these  centers  painfully 
manifest.  Doubtless  the  genital  center  lies  in  the  lumbar  portion  of  the  cord, 
though  automatic  visceral  ganglia  exist  in  the  genital  organs,  such  as  I  have 
formerly  designated  "automatic  menstrual  ganglia."  Such  ganglia  require 
a  month  to  accomplish  a  rhythmical  cycle;  they  explode  monthly.  In  the 
spinal  cord  there  exists  a  linear  row  of  cells  known  as  the  columns  of  the 
late  English  investigator,  Dr.  Clark.  Some  think  that  Clark's  columns 
exercise  the  function  of  vaso-motor  action,  i.  e.,  control  the  caliber  of  blood- 
vessels. But  as  Dr.  Fox  states,  this  column  of  Clark's  does  not  exist 
throughout  the  whole  length  of  the  cord.  Should  further  investigations 
demonstrate  that  Clark's  columns  have  a  vaso-motor  function  it  would  go  a 
long  way  in  proving  considerable  independence  of  the  sympathetic  nervous 
system. 

This  independence,  however,  does  not  entirely  depend  on  the  supposed 
vaso-motor  column  of  Clark.  Definite,  though  limited  independence  can  be 
observed  in  portions  of  the  sympathetic  nerve  by  any  one  who  will  carefully 
perform  experiments  on  the  lower  animals.  We  of  course  do  not  overlook 
the  idea  that  the  sympathetic  system  and  cerebrospinal  system  are  so 
intimately  co-related  that  one  so  blends  with  the  other  that  all  action  seems 
lost  in  the  cerebrospinal  mass. 

When  the  spinal  cord  and  brain  have  lost  control  of  the  intestines  they 
assume  a  wild  and  disordered  action,  as  may  be  seen  in  a  person  dying  of 
brain  disease.  In  casesjn  which  at  the  autopsy  we  could  discover  no  brain 
disease  I  have  found  from  one  to  four  invaginations  after  death.  In  such 
cases,  doubtless,  after  the  cessation  of  the  function  of  the  cerebrospinal 
masses,  the  sympathetic  fell  into  a  wild,  confused  and  disordered  action. 
The  muscular  wall  of  the  intestine  assumed  an  irregular  action  producing 
invagination.  This  latter  is  due  to  irregular  action  of  the  muscles  in  the 
intestinal  wall. 

In  a  certain  sense  we  may  look  at  the  nervous  system  as  composed  of 
two  parts,  viz. :  a  cerebrospinal  part  and  a  sympathetic  part,  connected  by 
a  number  of  single,  fine,  short,  non-medullated  strands.    These  strands  really 


198 


NERVES  OF  THE  HEART 


hearths  U%HlF  JI^TV*16.3  ^^  s-™pathetic  nerves  on  the  left  side  to  the 
cerv  icai In  in  \ti  h  1  N"^S  s  ganglion;  18  is  the  phrenic  joined  to  the  inferior 
cervical  ganglion  at  8  by  a  branch,  19.  This  connection  explains  the  brayine  sound  or 
expiratory  moan  on  sudden  rectal  dilatation.  ura.Mn^  souna  or 


ANATOMIC    AND    niYSIOLOGIC    CONSIDERATIONS         199 

connect  the  ganglia  of  the  sympathetic  with  the  brain  and  cord.  With  such 
a  constructed  apparatus  before  us  it  might  be  stated  that  the  sympathetic 
system  simply  consists  of  branches  of  the  cerebrospinal  system.  It  may  be 
represented  as  a  branched  roadway  which  distributes  forces  from  the  spinal 
cord  to  the  viscera.  It  may  be  considered  as  overflow  paths  to  carry  nervous 
energy  to  the  periphery.  The  ganglia  of  the  sympathetic  system  are  entirely 
outside  of  man's  will-power.  He  cannot  control  them  to  hasten  visceral 
action  or  retard  it.  It  is  plainly  of  utility  to  man  to  place  beyond  his  will- 
power the  action  of  viscera,  as  he  would  doubtless  abuse  it  from  selfish  and 
other  purposes. 

But  we  must  claim  that  the  sympathetic  nervous  system  is  more  than 
a  mere  branched  roadway  for  the  mere  distribution  of  nervous  energy  from 
the  cerebrospinal  axis.  If  nervous  energy  was  merely  to  flow  to  the  viscera 
from  the  cerebrospinal  axis,  why  all  this  complicated,  brain-like  apparatus 
in  the  various  sympathetic  ganglia?  No,  the  ganglia  of  the  sympathetic  are 
centers  of  nervous  energy,  accumulations  of  brain  cells,  of  reflex  centers, 
organized  receivers  of  sensation  and  transmitters  of  motion.  Is  the  cerebro- 
spinal system  closely  related  to  the  sympathetic  system  by  mere  relations  of 
structure,  because  the  sympathetic  ganglia  and  cells  are  imbedded  in  the 
great  centers,  or  is  it  because  the  cerebrospinal  system  has  intrinsic  and 
final  control  of  the  sympathetic? 

In  the  dorsal  region  we  find  the  typical  spinal  nerve  of  the  morphologist 
with  its  three  chief  divisions,  viz.;  (a)  dorsal;  (b)  ventral  and  (c)  visceral 
branch.  The  visceral  and  vaso-motor  branch  is  contained  in  the  ramus 
communicans,  which  passes  from  the  spinal  cord  to  the  lateral  chain  of  the 
sympathetic  or  lateral  ganglia,  the  demedullating  centers.  From  this  lateral 
chain  of  ganglia  nerves  pass  onward  to  a  second  chain  of  ganglia,  known  as 
the  prevertebral  or  collateral  ganglia,  i.  e.,  the  cardiac,  abdominal  brain, 
inferior  mesenteric  and  pelvic  brain.  Milne  Edwards  called  the  nerves  which 
pass  from  the  lateral  sympathetic  chain  to  the  collateral  (prevertebral) 
chain,  rami  efferentes.  Again,  from  the  prevertebral  (collateral)  ganglia  or 
plexus,  nerve  fibers  pass  into  smaller  terminal  ganglia  in  the  abdominal 
organs,  or  to  what  we  designate  the  automatic  visceral  ganglia.  We  also 
have,  besides  the  three  distinct  sets  of  sympathetic  ganglia,  connected  with 
the  ramus  communicans,  the  posterior  ganglia  at  the  roots  of  the  nerves  as 
they  issue  from  the  spinal  canal.  The  ramus  communicans  is  then  connect- 
ed with  four  distinct  ganglia: 

1.  The  root  ganglia  (proximal  ganglia),  i.  e.,  the  ganglia  situated  on  the 
posterior  spinal  nerves  immediately  after  issuing  from  the  cord. 

2.  The  lateral  chain  of  sympathetic  (proximal  sympathetic  ganglia). 

3.  The  prevertebral  ganglia  (distal  sympathetic  ganglia). 

4.  The  automatic  visceral  ganglia,  or  terminal  ganglia  (distal  sympa- 
thetic ganglia). 

Leaving  out  the  first  of  the  ganglia,  we  note  that  the  ramus  communi- 
cans connects  the  spinal  cords  with  three  great  systems  of  sympathetic  gang- 
lia, viz. :  (a)  the  lateral  chain  (b)  the  prevertebral  chain  and  (c)  the  automatic 


200 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


visceral  ganglia,  making  a  complicated  and  vast  system  distributed  over  a 
wide  area.  In  regard  to  the  relation  of  this  vast  sympathetic  system  to  the 
cerebrospinal  axis  in  general,  three  views  have  been  held: 

1.     The  first  and  perhaps  the  oldest  view  is  that  the  sympathetic  nervous 
system  possesses  a  very  great  independence  of  action.     The  supporters  of  this 


RENAL  VASCULAR  SUPPLY 

Fig.  55.  This  illustration  presents  corrosion  anatomy  of  3  kidneys.  The  renal  vascular 
blades  are  opened  like  a  book. 

The  abundance  of  sympathetic  nerves  may  be  estimated  by  the  fact  that  each  branch  of 
the  renal  artery  is  ensheathed  by  an  anastomatic  meshwork  a  fenestrated  network  of  nerves. 
The  renal  calyces  and  pelvis  lie  within  the  open  book.  For  nerves  of  the  digestive  tract 
see  Fig.  13. 


view  make  the  sympathetic  system  the  exclusive  center  of  motion  and  sensa- 
tion of  the  thoracic  and  abdominal  viscera.  The  chief  establishers  of  this  view 
are  Volkmann  (1842)  and  Bidder  (1844).  Their  able  defense  of  the  independ- 
ence of  the  sympathetic  nervous  system  is  still  entertained  and  published  in 
the  best  anatomies.  Bichat  (1800)  advocates  the  independence  of  the 
sympathetic  ganglia,   as  one  of  the  first   and  ablest   supporters.     In    fact 


ANATOMIC    AXD    PHYSIOLOGIC    CONSIDERATIONS        201 

Bichat  was  one  of  the  first  to  definitely  conceive  this  notion.  Before  me  lies 
a  rare  old  book  which  I  secured  from  an  old  English  collection.  It  is  written 
by  James  Davey,  1858,  on  "The  Ganglionic  Nervous  System."  Davey  gives 
Bichat  credit  for  knowledge  of  the  sympathetic  ganglion.  Davey  began  to 
advocate  the  primary  and  essential  independent  function  of  the  sympathetic 
in  1835,  as  is  recorded  in  the  "Lancet."  Fletcher  wrote  (1837)  on  the 
independent  action  of  the  sympathetic. 

2.  The  second  view  held  was  chiefly  established  by  Valentine  (1839). 
This  view  makes  the  sympathetic  system  an  offshoot  or  dependent  of  the 
cerebrospinal  system.  It  would  contain  no  fibers  except  those  in  the  brain 
and  spinal  cord. 

3.  A  third  view  considers  the  sympathetic  to  be  composed  of  fibers  from 
the  brain  and  cord,  and  also  of  other  fibers  which  arise  in  the  various  ganglia. 
According  to  this  view  every  sympathetic  nerve  trunk  contains  both  cerebro- 
spinal and  sympathetic  fibers.  This  view  should  consider  all  nerves  sympa- 
thetic which  arise  in  the  ganglia  and  preside  over  the  functions  of  the  organs. 

The  question  might  be  asked,  what  are  the  functions  of  the  sympathetic 
ganglia?  It  should  be  remembered  that  many  different  opinions  mean 
unsettled  views. 

1.     We  may  state  that  the  ganglia  demedullate  nerves. 

"_'.  More  nerves  pass  out  of  a  sympathetic  ganglia  than  enter  it ; 
hence  the  ganglion  is  likely  the  originator  of  nervous  fibers. 

3.  The  ganglia  possess  nutritive  powers  over  the  nerves  passing  from 
them  to  the  periphery. 

4.  They  are  centers  of  reflex  action,  i.  e.,  receivers  of  sensation  and 
transmitters  of  motion. 

We  are  therefore  to  consider  as  the  subject  of  our  theme: 

1.  The  rami  communicantes. 

2.  The  lateral  chain  of  sympathetic  ganglia. 

3.  The  prevertebral  plexuses  and 

4.  The  automatic  visceral  ganglia. 

There  are  some  differences  between  the  sympathetic  system  and  cerebro- 
spinal axis  which  may  be  noted  and  discussed  later. 

1.  We  may  claim  that  the  sympathetic  nerves  are  the  visceral  branches 
of  the  spinal  nerves  and  hence  have  a  distinct  function,  if  not  structure. 

2.  The  individual  fibers  of  the  sympathetic  nerves  are  of  smaller  caliber 
than  those  of  the  cerebrospinal  or  somatic  nerves. 

3.  The  sympathetic  branches  preponderate  in  non-medullated  nerves. 

4.  The  fibers  of  the  sympathetic  nerves  are  interrupted  by  nerve  cells  or 
ganglia  through  which  they  pass. 

5.  Nerve  cells  are  liable  to  accumulate  into  ganglia  along  a  non-medul- 
lated nerve. 

6.  The  sympathetic  nerves  tend  to  form  closely  meshed  networks  or 
plexuses,  as  Auerbach's  and  Billroth-Meissner's  plexuses. 

7.  The  somatic  (cerebrospinal)  nerves  supply  the  body  wall.  The 
sympathetic  nerves  supply  the  viscera.  In  the  visceral  nerves  must  be 
included  vascular  nerves. 


202 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


We  might  call  the  various  systems  of  ganglia  of  the  sympathetic  by 
numbers.  For  example,  the  lateral  chain  of  sympathetic  ganglia  may  be 
called  primary  ganglia.  In  the  primary  ganglia  the  chief  nerves  of  the  rami 
communicantes  pass. 

Again,  we  might  call  the  prevertebral  plexuses,  the  secondary  ganglia. 
Many  nerves  from  the  rami  communicantes  enter  the  secondary  ganglia  with- 
out entering  the  primary  ganglia. 


NERVES  OF  TRACTUS  GENITALIS 

Fig,  56.    This   illustration  presents  the  nerves  of  the  genitals  according   to    Franken- 
hauser. 


Finally  the  automatic  visceral  ganglia  might  be  called  tertiary  ganglia. 
In  short  we  could  conveniently  speak  of  the  primary,  secondary  and  tertiary 
system  of  sympathetic  ganglia. 

Much  interest  is  attached  to  the  ramus  communicans,  i.  e.,  the  narrow 
isthmus  which  joins  the  cerebro-spinal  axis  to  the  sympathetic  system  It  is 
important  to  have  a  clear  view  of  these  rami  communicantes,  for  through 
them  pass  the  rami  visceraes  and  rami  vasculares,  i.  e.,  the  rami  communi- 
cantes contain  and  transmit  the  vascular  and  visceral  nerves,  both  subjects 
of  profound  practical  interest  in  medicine  and  surgery. 


ANATOMIC    AND    PHYSIOLOGIC    CONSIDERATIONS         203 

In  an  anatomical  sense  writers  understand  by  the  term  rami  communi- 
cantes,  two  short  nerves,  a  double  connection  between  the  cerebrospinal  axis 
and  the  sympathetic  system,  i.  e.,  with  the  lateral  chain  or  primary  ganglia. 
One  ramus  communicans  is  white,  medullated  and  passes  directly  out  of  the 
anterior  root  of  the  spinal  cord  chiefly  to  the  lateral  chain,  but  some  fibers 
pass  directly  to  the  prevertebral  plexus.  This  branch  of  the  communicans 
contains  the  visceral  and  vascular  nerves;  hence  the  importance  to  all 
practitioners.  The  other  ramus  communicans  is  gray,  non-medullated  and 
passes  from  the  lateral  chain  of  ganglia  to  the  spinal  cord.  It  is  a  vaso- 
motor nerve,  the  purpose  of  which  is  to  regulate  the  vessels  of  the  cord  and 
its  meninges.  It  is  well  to  remember  that  the  term  ramus  communicans 
is  a  general  term  including  all  the  kinds  of  nerves  which  supply  the  viscera 
and  blood-vessels. 

I  propose  here  to  consider  at  some  length  the  ramus  communicans  which 
supplies  the  abdominal  viscera  and  blood-vessels.  In  the  first  place,  there 
are  certain  fine,  white,  medullated  nerves,  as  Gaskell  has  pointed  out,  which 
pass  from  the  spinal  cord,  in  the  white  ramus  communicans  between  the 
second  dorsal  and  second  lumbar  nerves  inclusive,  to  supply  the  viscera  and 
blood-vessels.  These  nerves  should  be  named  as  Gaskell  suggests,  splan- 
chnics.  Hence  we  will  have:  (1)  the  thoracic  splanchnics;  (2)  the  abdominal 
splanchnics  and  (3)  the  pelvic  splanchnics:  A  peculiar  feature  of  these  white 
rami  communicantes  is  that  they  are  only  found  in  a  limited  region  of  the 
spinal  column.  They  begin,  as  Gaskell  notes,  at  the  second  dorsal  and  end 
in  the  second  lumbar.  They  have  a  very  fine  caliber  and  pass  into  the 
lateral  chain,  where  they  become  demedullated,  and  second  into  the  prever- 
tebral plexuses  where  the  remainder  become  non-medullated.  Hence,  all 
the  white  rami  communicantes  which  pass  through  sympathetic  ganglia 
leave  the  ganglia  as  non-medullated  or  as  sympathetic  nerves  to  attend  to 
viscera  and  blood-vessels.  Above  the  second  dorsal  vertebra  the  rami  com- 
municantes consist  of  the  gray  variety,  i.  e.,  they  are  peripheral  nerves  of  the 
lateral  ganglia.  Below  the  second  lumbar  vertebra  they  are  also  of  the  gray 
peripheral  variety. 


CHAPTER  XVII 

THE    PHYSIOLOGY  OF    THE  ABDOMINAL   AND    PELVIC    BRAIN 
WITH  AUTOMATIC    VISCERAL  GANGLIA. 

The  sympathetic  nerve    which  rules  visceral  rhythm  never    sleeps.      Visceral 
rhythm  {peristalsis)  and  life  are  beyond  the  control  of  the  will. 

'Precedent  is  the  terror  of  second  rate  men." — Dr.  Joseph  Parker. 

The  physiology  of  the  abdominal  and  pelvic  brain  with  automatic 
visceral  ganglia  comprehends  the  real  physiology  of  the  sympathetic,  as  the 
chief  portion  of  the  former  is  included  or  counted  in  the  latter.  It  may  be 
asked,  "What  is  understood  by  the  physiology  of  the  sympathetic  nerve?" 
We  understand  by  the  physiology  of  any  organ  the  use  it  yields  to  the  econ- 
omy, or  the  purpose  it  subserves  to  the  animal.  It  may  be  stated  in  the 
beginning  that  it  is  difficult  to  definitely  and  exactly  define  the  physiology  of 
the  sympathetic  nerves,  as  they  are  often  largely  mingled  with  those  of  the 
cerebrospinal  system.  The  cerebrospinal  and  sympathetic  systems  of  nerves 
have  a  certain  initial  dependence  on  each  other,  like  the  individuals  of  well- 
ordered  society.  Yet  certain  limited  liberties  are  assumed  by  both  systems. 
The  Federal  government  presides  as  a  central  power  over  the  various  states, 
but  the  latter  assume  many  independent  liberties  of  action.  The  states  act 
and  execute  independently  of  the  central  government.  So  it  is  in  the  human 
body,  an  exquisitely  perfect  product  of  millions  of  ages;  the  sympathetic 
nerve,  though  dependent  for  much  of  its  power  on  the  cerebrospinal  axis, 
has  in  its  influence  over  circulation  and  the  abdominal  viscera  a  certain  inde- 
pendence of  function. 

The  sympathetic  is  not  merely  an  agent  of  the  brain  and  cord.  It 
generates  action  itself.  It  is,  in  general,  a  nerve  center  characterized  by  the 
power  to  receive  sensation  and  send  out  motion.  It  has  all  the  elements  of 
any  nervous  system,  viz. :  a  ganglion  cell,  a  conducting  cord  and  and  a 
periphery.  It  is  not  attempted  here  to  argue  that  either  the  cereborspinal 
axis  or  the  sympathetic  nerve  is  absolutely  independent  of  the  other.  The 
fact  is  that  each  nerve  system  has  its  own  special  duties.  Both  systems  must 
be  associated  in  order  to  carry  on  life's  functions  and  purposes.  It  may  be 
said  that  man  and  woman  are  independent  of  each  other;  but  their  associa- 
tion is  required  for  the  perfection  of  reproduction.  In  another  place  I  have 
arranged  quite  a  number  of  propositions  to  show  that  the  sympathetic  nerve 
enjoys  a  large  degree  of  independence.  In  the  discussion  of  its  physiology 
certain  topics  must  be  discussed,  in  order  to  better  comprehend  the  limits  and 
factors  of  the  field. 

1.  The  abdominal  pelvic  brain,  i.  e.,  reorganizing  centers. 

2.  A  very  important  factor  will  be  the  vaso-motor  nerves  (i.  e.,  vaso- 
constrictors and  vaso-dilators). 

204 


ANATOMY   AND   PHYSIOLOGY  205 

3.  The  automatic  visceral  ganglia. 

4.  Glandular  secretions  (bile,  urine,  gastro-intestinal  juices,  milk,  ova 
and  semen). 

5.  Temperature. 

6.  Trophic  nerves. 

7.  Pigmentation. 

8.  Reflex  fibers. 

9.  Sleep. 

The  above  nine  divisions  mark  out  a  field  for  consideration.  It  may  be 
broadly  stated  that  all  healthy  movements  initiated  and  sustained  by  the 
sympathetic  nerves  are  involuntary  movements. 

The  vaso-motor  nerves.  They  are  divided  into  vaso-constrictors  and 
vaso-dilators,  and  to  Claude  Bernard  belongs  the  credit  of  first  conclusively 
showing  (in  1851)  that  they  exerted  an  influence  over  the  caliber  of  the  ves- 
sels. Authors  agree,  in  general,  that  here  are  vaso-motor  centers  located  in 
the  spinal  cord  which  control  the  caliber  of  vessels.  Some  place  the  vaso-mo- 
tor centers  in  the  vascular  columns  of  Clark.  Still  another  set  of  authors  of 
great  respectability  claim  that  vaso-motor  centers  are  located  along  the 
peripheral  nerve  branches.  Doubtless  there  are  in  the  walls  of  vessels  nerve 
cells  which  are  in  connection  with  the  vaso-motor  nerves.  These  vascular 
ganglia,  or  nerve  cells,  send  fibers  to  the  muscularis  of  the  vessel,  dilating  or 
contracting  it  according  to  the  nature  of  the  despatched  stimulus. 

It  is  not  yet  definitely  settled  whether  the  vaso-motor  nerves  are  con- 
strictors or  dilators,  or  whether  there  are  distinct  constrictors  and  dilators. 
Some  assert  that  there  is  a  constrictor  nerve  only  and  that  dilation  of  the 
vessel  is  paresis  of  the  constrictor.  Later  authority  seems  to  point  to  a 
vaso-dilator  and  vaso-constrictor,  and  the  fact  that  there  are  vaso-motor 
centers  located  on  the  vessel  or  adjacent  to  it.  It  is  evident  to  observers  and 
clinicians  that  local  variation  of  circulation  occurs  in  the  genital  or  digestive 
tracts  from  reflex  irritation.  By  slight  irritation  one  can  produce  a  white 
line  (vaso-constriction)  and  by  more  severe  irritation  one  can  produce  a  red 
line  (vaso-dilation).  Cold  first  constricts  the  vessels,  but  it  is  rapidly 
followed  by  vaso-dilation,  a  redness.  Now,  this  local  variation  of  circulation 
occurs  doubtless  with  more  distinctness  in  the  visceral  organs  which  are  so 
highly  supplied  with  vaso-motor  nerves,  and  so  closely  situated  to  the 
gigantic  vaso-motor  center,  the  abdominal  brain.  The  significance  of  vaso- 
constricting  nerves  becomes  very  evident  when  it  is  recognized  that  they  are 
so  powerful  that  they  can  drive  or  squeeze  all  the  blood  out  of  a  part. 

In  death  from  peritonitis  the  vaso-constrictors  drive  first  all  the  blood 
out  of  the  skin  or  periphery.  The  blood  is  forced  into  the  large  arteries  and 
veins  by  the  effect  of  the  vaso-constrictors  on  the  peripheral  and  smaller 
vessels.  The  vaso-dilators  may  be  so  effectively  exercised  that  the  blood 
escapes  through  the  wall  of  the  blood-vessels  as  in  hemorrhagic  peritonitis. 

The  vaso-motor  nerves  are  of  the  sympathetic  and  exercise  control  over 
the  caliber  of  vessels.  The  controlling  of  the  lumen  of  vessels  constitutes  a 
vast  field  of  physiology,  in  the  domain  of  the  sympathetic.     It  constitutes 


206  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

vascular  tone.  Section  of  the  sympathetic  dilates  the  vessels  beyond  the 
normal.  One  of  the  chief  offices  of  the  sympathetic  nerve  is  to  preserve  the 
tone  of  vessels.  The  nerves  that  insure  tone  in  vessels  issue  from  the  sym- 
pathetic. They  are  always  active  and  never  in  repose, — a  characteristic  of 
the  sympathetic  nerve.  They  pass  to  the  muscular  coat  of  the  vessels  and 
act  as  their  permanent  guardian,  in  preserving  permanent  vascular  tone. 
Variation  in  this  tone  constitutes  incipient  disease.  Doubtless  the 
vascular  tone  is  the  result  of  a  reflex  matter,  and  the  factor  in  the  reflection 
is  the  blood-wave,  i.  e.,  the  trauma  or  irritation  of  the  blood-wave  on  the 
endothelial  membrane  of  the  vessel  induces  the  vaso-constrictors  to  act  per- 
manently in  preserving  vascular  tone.  Congestion  is  only  the  abolition  of 
vascular  tone.  Goltz's  percussion  experiment  demonstrates  the  reflex  nature 
of  the  action  of  vaso-motor  nerves,  as  by  tapping  on  the  exposed  viscera  he 
could  produce  dilatation  of  their  vessels.  Hence  in  this  case  the  centers  for 
reflex  action  must  lie  in  the  walls  of  the  vessels  themselves. 

For  a  reflex  act  in  the  vaso-motor  field,  there  must  exist  several  factors, 
as  (a)  muscular  walls  or  contractile  tissue;  (b)  centripetal  fibers;  (c)  a  center 
of  reflection;  (d)  centrifugal  fibers. 

All  these  factors  exist  on  and  adjacent  to  vessels. 

For  the  reflex  centers  of  vaso-motor  movements  we  may  look  to  the 
cardiac  ganglia,  the  abdominal  brain  or,  especially,  to  the  ganglia  around  the 
vessels  or  in  their  walls.  Finally,  we  may  claim  that  the  vaso-motor  nerves 
control  the  caliber  of  vessels,  that  they  belong  to  the  sympathetic  and  that 
those  of  the  abdominal  viscera  are  chiefly  under  the  control  of  the  gigantic 
vaso-motor  center — the  abdmoinal  brain. 

First,  we  must  consider  the  abdominal  brain,  the  semilunar  ganglia  or 
solar  plexus,  in  the  physiology  of  the  smypathetic.  This  large  ganglion 
receives  sensation  and  sends  out  motion.  It  is  situated  at  the  root  of  the 
great  visceral  artery  i.  e.,  at  the  foot  of  the  celiac  axis.  It  lies  behind  the 
stomach  and  entwines  itself  about  the  aorta  and  root  of  the  celiac  axis  and 
superior  mesenteric  artery.  In  short,  it  is  located  at  the  roots  of  the  celiac, 
renal  and  superior  mesenteric  arteries.  It  supplies  all  the  abdominal  viscera. 
It  is  a  gigantic  vaso-motor  center  for  the  viscera,  as  is  shown  by  its  location 
at  the  roots  of  the  celiac,  renal  and  superior  mesenteric  arteries — the  great 
abdominal  visceral  blood  way.  It  is  connected  with  almost  every  organ  in 
the  body,  with  a  supremacy  over  visceral  circulation,  with  a  control  over 
visceral  secretion  and  nutrition,  with  a  reflex  influence  over  the  heart  that 
often  leads  to  fainting  and  may  even  lead  to  fatality.  It  rules  visceral 
rhythm.  No  wonder  that  we  may  consider  the  abdominal  brain  the  center 
of  life  itself,  as  the  cranial  brain  is  the  center  of  mental  and  psychical  forces! 

The  abdominal  brain,  or  solar  plexus,  is  composed  of  the  aggregation  of 
coalescence  of  a  large  number  of  ganglia.  On  the  two  sides  of  the  abdomi- 
nal brain  are  situated  the  semilunar  ganglia — compact  masses  of  nerve  cells, 
nerve  cords  and  connective  tissue.  During  many  dissections  I  have  noted 
that  the  right  semilunar  ganglion  is  the  smaller,  doubtless  because  it  lies 
behind  the  inferior  vena  cava,  and  hence  has  suffered  from  pressure  atrophy. 


ANATOMY    AND    rilYSIOLOGY  207 

Each  of  the  semilunar  ganglia  receives  the  great  splanchnic  nerve  of  the 
corresponding  side.  The  other  splanchnics  may  enter  it,  but  it  is  more  to 
enter  the  abdominal  brain.  It  may  be  here  stated  that  although  the  semi- 
lunar ganglia  are  located  on  the  sides,  they  are  practically  so  intimately 
associated  with  the  solar  plexus  that  we  insist  in  combining  all  the  names 
into  one,  viz.  :  that  of  Abdominal  Brain. 

All  plexuses  or  strands  of  nerves  are  secondary.  The  significance  of  the 
abdominal  brain  in  the  visceral  physiology,  i.  e.,  in  life,  may  be  compared  to 
that  of  the  sun  over  the  planets.  The  influence  of  the  sun  rules  the  planets, 
though  they  are  influenced  by  other  suns  and  planets  (e.  g.,  the  cerebro- 
spinal). The  abdominal  brain  has  ganglion  cells  (brain  centers),  nerve 
strands  (nerve  conductors)  and  a  peripheral  nerve  apparatus,  just  as  the 
cranial  brain  possesses  a  central,  conducting  and  peripheral  apparatus.  The 
abdominal  brain  can  live  without  the  cranial  (shown  by  living  fetuses  with 
no  trace  of  cerebrospinal  axis),  while  the  cranial  brain  and  the  cord  cannot 
live  without  the  abdominal  brain. 

The  great  sympathetic  ganglia,  of  which  the  abdominal  brain  is  the 
ruling  potentate,  is  the  center  of  life  itself.  So  long  as  the  forces  of  life, 
assimilation,  circulation,  respiration  and  secretion  proceed  undisturbed,  as  in 
health,  the  abdominal  brain  remains  a  silent,  steady,  but  ceaseless  worker; 
but  being  unbalanced  by  peripheral  or  central  irritation,  it  quickly  manifests 
or  resents  the  insult.  From  the  abdominal  brain  large  plexuses  with  numer- 
ous nerve  strands  pass  to  every  abdominal  viscus,  connecting  the  viscera  into 
a  delicately  balanced,  nicely  ordered,  exquisitely,  arranged  apparatus  for  the 
object  of  maintaining  life.  The  nerve  plexuses  or  strands  are  arranged  along 
the  highways  of  nourishment — blood  and  lymph  vessels,  and  vary  in  size 
according  to  the  importance  of  the  viscus  supplied. 

Laignel  and  Lasvastine,  in  their  experiments  upon  dogs,  have  found  that 
ablation  of  the  solar  plexus  is  a  serious  operation ;  though  traumatism  of  the 
plexus  even  may  cause  death.  They  have  called  the  solar  syndrome  of 
paralysis  the  sum  of  symptoms  produced  by  ablation  of  the  plexus;  it  may 
be  superacute,  acute,  subacute,  or  chronic.  The  first  form  they  have  found 
to  be  present  in  peritonitis,  clinically,  the  second  in  lead  colic;  the  others  in 
mucomembranous  colitis.  Certain  affections,  therefore,  may  be  attributed 
solely  to  disturbance  of  the  solar  plexus,  and  not  to  general  systemic 
derangement. 


CHAPTER    XVIII. 

CONSIDERATIONS  FOR  THE   REMOVAL  OF  PELVIC  AND 
ABDOMINAL    TUMORS. 

The  sympathetic  is  the  silent  companion  of  the  cerebrospinal.     The  sympathetic 
nerve  is  the  nerve  of  subconscious  life. 

"But  he  did  not  lose  sight  of  the  present  in  these  glowing  visions  of  a  future." — 
Mrs.  Catharine  V.  Waitc,  "The  Mormon  Prophet  and  His  Harem." 

Having  devoted  some  twenty  years  to  the  study  of  pelvic  and  abdominal 
visceral  disease,  I  have  frequently  desired  to  record  some  observations  on 
the  effect  of  tumors  in  the  pelvis  and  abdomen  upon  the  sympathetic  system. 
Many  dissections  have  convinced  me  that  the  vast  ganglionic  system,  dis- 
tributed to  the  viscera  bordering  upon  the  peritoneal  cavity,  together  with 
other  glandular  organs  of  the  body,  plays  a  significant  role.  Besides,  when 
it  is  noted  that  the  heart  and  the  unstriped  muscles  of  the  body,  are  supplied 
by  the  sympathetic  system,  there  becomes  at  once  apparent  its  extensive  as 
well  as  intimate  connection  with  the  whole  body. 

Special  study  in  the  physiology  and  pathology  of  the  viscera  develops 
reasons  for  the  removal  of  abdominal  and  pelvic  tumors  not  apparent  from 
superficial  observations.  It  is  well  known  that  shortly  after  the  appearance 
of  a  tumor  in  the  abdomen  the  health  of  the  patient  becomes  more  or  less 
impaired.  The  functions  of  the  organs  become  deranged;  the  heart  suffers 
from  abnormal  action  and  structural  change;  the  digestion  becomes  more  or 
less  deranged.  As  the  tumor  increases  in  size,  kidney  diseases  generally 
develop.  The  liver,  forming  bile,  glycogen  and  urea,  sooner  or  later  becomes 
impaired  in  its  rhythm.  The  lungs  lose  their  rhythm  and  become  spasmodic, 
while  the  spleen  shows  its  disturbance  by  pigmentary  deposits  in  various 
portions  of  the  body.  An  attempt  will  here  be  made  to  explain  the  patho- 
logical result  of  abdominal  tumors  on  physiological  and  anatomical  grounds. 

The  basis  of  the  explanation  will  be  by  reflex  action  on  the  sympathetic 
nerve.  It  may  be  curtly  observed  that  pathological  results  due  to  the  sym- 
pathetic nerve  are  based  upon  reflex  action.  We  shall  assume  that  the 
ganglia  which  are  found  in  it,  especially  the  abdominal  brain  and  the  three 
cervical  ganglia,  are  points  where  forces  are  reorganized  and  distributed  to  the 
viscera.  The  first  essential  feature  to  observe  in  the  diseased  viscera  is  the 
disturbance  in  rhythm.  Though  any  abdominal  tumor  may  produce  the  same 
results,  we  shall  choose  a  uterine  myoma  to  illustrate  our  views.  It  is  a 
principle  in  physiology  that  when  a  peripheral  irritation  is  sent  to  the 
abdominal  brain  the  reorganized  forces  will  be  emitted  along  the  lines  of 
least  resistance,  so  that  the  organ  which  is  supplied  with  the  greatest  number 
ot  nerve  strands  will  suffer  the  most.  Practically  this  principle  holds  true  in 
every  viscus. 

208 


REFLEX   ACTION 


209 


The  great  ganglia  and  cords,  filled  with  nerve  cells  and  nerve  strands, 
labor  in  the  subconscious  region,  the  vast  laboratory  of  life  and  assimilation. 
The  cerebrospinal  axis  receives  sensations  and  emits  impulses  which  express 
themselves  in  motion,  performing  labors  which  minister  to  the  mind  and 
protect  the  body  in  avoiding  destruction,  or  contribute  to  its  nutrition. 


SCHEMATIC  DRAWING  OF  THE  SYMPATHETIC  NERVE 

Fig.  57.  X,  ganglion  of  Ribes ;  y,  coccygeal  ganglion ;  h,  heart ;  k,  kidney ;  s,  spleen ; 
a  b,  abdominal  brain ;  s  p,  sptrmatic  (ovarian  plexus) ;  i,  intestine ;  h  p,  hypogastric  plexus  ; 
c  g,  the  three  cervical  nerves. 

The  sides  of  the  ellipse  represent  the  lateral  chain  of  the  sympathetic.  All  the  nerve 
strands  report  to  the  abdominal  brain. 

The  effects  of  the  tumor  on  the  heart  may  first  be  considered.  An 
abdominal  tumor  induces  fatty  degeneration  of  the  heart.  When  the  uterine 
tumor  irritates  the  peripheral  ends  of  the  hypogastric  plexus,  the  irritation 
is  transmitted  to  the  abdominal  brain  and  there  reorganized  and  emitted 
along  the  splanchnic  to  the  cervical  ganglia,  where,  again,  a  reorganization 
occurs  and  the  force  then  passes  down  to  the  heart  by  way  of  the  three  car- 

14 


210  THE  ABDOMINAL  AND  PELVIC  BRAIN 

diac  nerves.  The  irritation  could  pass  directly  from  the  uterine  myoma  up 
to  the  lateral  chain  of  sympathetics  to  the  three  cervical  ganglia  where  it 
becomes  reorganized. 

It  no  doubt  transmits  part  of  the  irritation  by  way  of  the  abdominal  brain 
and  part  by  way  of  the  lateral  chain.  So  far  as  the  heart  is  concerned,  the 
result  is  nearly  the  same,  for  the  irritation  is  reorganized  in  each  case  in  the 
three  cervical  ganglia  and  transmitted  to  the  heart.  It  is  of  course  necessary 
to  consider  that  the  irritation  may  be  sent  to  the  spinal  cord  by  way  of  the 
vagus  and  there  reorganized.  In  such  case  it  is  sent  directly  to  the  heart  by 
the  vagus. 

It  should  be  remembered  that  the  sympathetic  ganglia  in  the  walls  of  the 
heart  (Ludwig's,  Bidder's,  Schmidt's  and  Remak's)  are  numerous  and  large. 
Also  that  the  network  of  cords  with  their  ganglia,  situated  close  to  its  surface, 
constitute  an  extensive  nerve  system.  It  consists  of  the  great  or  deep  cardiac 
plexus,  otherwise  known  as  the  plexus  magnus  profundus  of  Scarpa,  besides 
the  superficial  cardiac  plexus,  with  the  cardiac  ganglia  of  Wrisberg,  which  is 
occasionally  large  from  the  coalescence  of  several  ganglia,  and  may  be 
represented  by  a  meshwork.  In  tumors  of  the  pelvis  we  are  dealing  with  the 
effect  on  the  vast  cardiac  sympathetic  nervous  system.  The  first  manifest 
objective  heart  symptom  is  irregularity. 

The  irritation    from  the  uterine  myoma  reaches  the  heart  in  two  ways: 

1.  The  irritation  passes  up  the  hypogastric  plexus  to  the  abdominal 
brain,  where  it  is  reorganized  and  emitted  to  all  the  viscera  over  their 
respective  sympathetic  plexuses.  In  the  case  of  the  heart  it  passes  up  the 
abdominal  splanchnics  to  the  three  cervical  ganglia  of  the  sympathetic, 
where  it  is  reorganized  and  sent  directly  to  the  heart. 

2.  Some  of  the  irritation  is  transmitted  by  way  of  the  vagi  to  the 
medulla,  where  it  is  reorganized  and  sent  directly  to  the  heart  by  the  cardiac 
nerves  which  supply  the  heart  from  the  vagus.  This  is  more  especially  the 
case  in  the  right  vagus,  as  that  is  the  cranial  nerve  which  largely  rules  and 
supplies  the  heart  and  abdominal  brain.  Now,  this  irritation  from  the 
myoma  goes  on  day  and  night.  It  gives  the  heart  no  rest.  It  flows  to  the 
heart  in  the  midst  of  a  diastole,  or  a  systole.  The  first  great  characteristic 
of  the  heart  (rhythm)  is  lost.  Having  lost  its  rhythm,  the  heart  proceeds 
irregularly.  Irregular  action  means  a  changed  nourishment;  continued 
irritation  with  disturbed  rhythm  induces  the  heart  to  overfeed  itself,  the 
result  being  hypertrophy. 

It  may  be  noted  that  this  hypertrophy  is  not  brought  about  in  precisely 
the  same  way  as  is  hypertrophy  from  valvulitis  or  aortic  insufficiency ;  but 
vaso-motor  dilation  must  play  a  role  in  over-nourishing  the  cardiac  muscles. 
It  resembles  more  nearly  the  cardiac  hypertrophy  existing  in  goiter.  That 
from  the  reflex  irritation  in  myoma  is  also  a  moderate  hypertrophy,  so  far  as 
the  writer  has  observed,  and  it  is  a  very  slow  process.  In  the  first  stage  the 
heart  becomes  irregular,  in  the  second  hypertrophied,  in  the  third  it  takes 
on  fatty  degeneration.  This  is  no  doubt  a  preservative  process,  so  that  a 
large,  vigorously  beating  heart  will  not  rupture  an  artery  in  a  degenerated 


ORGANS    EFFECTED    BY    REFLEXES  211 

state  (atheromatous  or  fatty).  It  appears  certain  that  many  old  cases  of 
large  uterine  myoma  are  lost  after  skillful  operations  simply  from  fatty 
degeneration  of  the  heart.  It  is  common  to  observe  palpitation  in  patients 
having  uterine  myoma,  and  palpitation  is  the  characteristic  symptom  of  a 
weak  heart. 

The  automatic  cardiac  ganglia  are  disturbed  by  reflex  irritation  and 
take  on  an  excessive  nourishment.  The  irritation,  sent  to  the  heart  over  the 
hypogastric  plexus,  is  in  one  sense  an  increased  demand  for  action.  The 
irritation,  passing  to  the  heart  day  and  night,  winter  and  summer,  according 
to  a  physiological  law,  provokes  hypertrophy,  if  the  nutritive  powers  are 
good.  If  they  are  not  good,  the  complement  of  hypertrophy — dilation — 
results. 

A  fatty  degenerated  or  weak  heart  induces  low  blood-pressure,  which  is 
the  bottom  factor  in  waste-laden  blood  and  deficient  elimination.  It  allows 
local  congestions  and  consequent  impaired  nourishment.  The  local  force  of 
such  circumstances  teaches  to  remove  uterine  and  other  abdominal  tumors 
as  early  as  possible,  so  that  the  patient  will  not  be  left  with  partially  or  com- 
pletely damaged  viscera. 

Reflexes  arising  from  the  irritation  of  the  sympathetic  in  the  peritoneal 
membrane  are  profound  in  results.  Irregularity,  hypertrophy,  and  degenera- 
tion of  the  heart  are  the  effects  of  a  reflex  act,  accomplished  mainly  through 
the  sympathetic  system  and  due  to  irritation  at  the  periphery  of  the  hypo- 
gastric plexus.  It  is  transmitted  to  the  abdominal  brain,  to  the  three 
cervical  ganglia,  and  some  to  the  spinal  cord,  whence  the  reorganization  of 
the  forces  occurs. 

The  organized  nervous  impressions  then  pass  to  the  heart  over  the  six 
cardiac  (vagi)  nerves.  This  abnormal  force  deranges  the  fine  balance  of  the 
heart's  rhythm.  The  automatic  cardiac  ganglia  become  discolored,  and  in 
time  vaso-motor  action  and  consequently  nourishment  are  disturbed. 

It  may  be  remembered  that  the  untoward  influence  on  the  heart,  disturb- 
ing its  rhythm  and  consequently  its  nourishment,  is  also  aided  and  abetted  by 
disturbing  the  caliber  of  distal  blood-vessels  which  are  controlled  by  the 
sympathetic  system. 

The  liver  does  not  escape  the  evil  influence  of  the  tumor.  Abdominal 
tumors  induce  fatty  degeneration  of  the  liver.  It  may  be  asserted  that  an 
influence  on  the  hepatic  plexus  of  nerves  alone  could  stop  all  scretion  in  the 
liver.  If  such  a  proposition  be  true,  it  need  not  be  wondered  that  lesser  irri- 
tations of  the  hepatic  nerve  plexus  could  so  alter  the  secretion  of  the  liver 
that  it  would  degenerate  the  organ.  The  characteristic  disturbance  which 
arises  from  the  uterine  myoma  is  a  derangement  of  rhythm.  The  liver  has  a 
rhythm  due  to  (a)  an  elastic  peritoneum  inclosing  it,  (b)  an  elastic  capsule 
(Glisson's)  surrounding  it,  and  (c)  to  the  capacity  of  its  cells  to  enlarge. 

The  occasion  of  the  liver  rhythm  is  food  carried  to  it  by  way  of  the 
portal  vein.  When  the  peritoneal  and  Glisson's  capsules  and  the  cells  are 
expanded  to  a  maximum,  the  liver  rhythm  is  at  its  climax.  Now,  the  prod- 
ucts of  the  liver  (bile,  glycogen  and  urea)  are  sent  to  their  respective  homes 


212  THE  ABDOMINAL  AND  PELVIC  BRAIN 

by  contraction  of  the  elastic  peritoneum  and  capsule  of  Glisson.  The  liver 
then  gets  its  rest  and  repair. 

The  irritation  from  the  periphery  of  the  hypogastric  plexus  passes  up 
to  the  abdominal  brain,  where  it  is  reorganized  and  emitted  to  the  liver.  It 
goes  to  the  liver  from  the  tumor  at  all  hours  and  deranges  its  rhythm.  The 
irritation  may  attempt  to  induce  a  rhythm  without  food,  or  it  may  flash  on  to 
the  liver  at  any  stage  in  its  rhythm.  The  liver  rhythm  is  induced  by  the 
automatic  hepatic  plexus.  So  it  may  be  asserted  that  the  irritation  of  the 
uterine  myoma  deranges  the  rhythm  of  the  liver. 

The  second  point  to  consider  is  the  altered  secretion  in  the  liver,  due  to 
the  reflex  irritation  from  the  uterine  myoma  by  way  of  the  abdominal  brain. 
The  continued  irritation  increases  the  derangement  and  soon  changes  and 
impairs  the  liver  nourishment.  The  complete  process  from  food  to  end  pro- 
ducts becomes  imperfect  and  a  lower  grade  of  tissue  is  formed,  known  as  fat. 
The  constantly  irritated  liver  soon  becomes  able  to  form  but  little  products 
beyond  fat,  and  degeneration  follows. 

It  is  well  known  that  women  at  the  menopause  frequently  acquire  liver 
disease.  This  is  owing  to  the  reflex  irritation  through  the  abdominal  brain. 
The  degeneration  of  the  hypogastric  plexus  will  not  allow  it  to  transmit 
sufficient  physiological  orders  to  induce  a  monthly  rhythm,  so  the  accumu- 
lated energies  flash  to  the  other  organs,  and  the  derangement  of  the  liver  is 
especially  manifest,  because  its  derangement  is  often  followed  by  pigmenta- 
tion (  yellow  or  brown  or  black)  of  the  skin.  The  uterine  myoma,  then,  by 
reflex  action,  disturbs  rhythm  and  secretion  in  the  liver,  and  so  its  nutrition. 
This  ends  in  fatty  degeneration. 

For  years  I  have  observed  that  women  with  pelvic  disorders  have  dis- 
turbed kidney  action.  In  general  this  kidney  disturbance  is  renal  insuffic- 
iency, and  it  may  after  long  irritation  become  organic  disease.  It  may  be 
well  to  give  a  general  hint  here  as  to  why  the  kidneys  suffer  so  much  when 
either  irritating  tumors  or  inflammatory  processes  exist  in  the  pelvic  organs. 

The  kidneys,  uterus,  ovaries  and  oviducts  develop  from  two  very  small 
points  in  the  embryo  called  the  Wolffian  bodies.  These  develop  from  the 
mesoblast,  as  do  the  muscles,  blood  and  lymph  vessels,  and  from  the  genito- 
urinary organs.  Arising  from  the  same  source  and  supplied  by  the  same 
nerves  and  blood-vessels,  the  Wolffian  bodies,  the  kidneys  and  genitals  have 
an  intimate  and  close  connection.  The  abdominal  brain  sends  out  a  vast 
chain  of  nerves  to  the  kidney  on  each  side,  and  the  same  brain  sends  out  a 
vast  chain  on  each  side  of  the  genitals.  These  and  the  kidneys  are  only 
different  spokes  in  the  same  wheel,  the  hub  of  which  is  the  abdominal  brain. 
Diseases  in  the  genitals,  whether  tumors  or  inflammatory  processes,  produce 
in  the  urine  not  only  diminished  solids  but  also  diminished  fluids. 

Again  on  the  other  hand  diminished  kidney  excretion  (renal  insufficiency) 
produces  diseased  or,  at  least,  disturbed  genitals.  Any  gynecologist  of  some 
years'  experience  has  doubtless  frequently  observed  that  in  women  with 
diseased  genitals  and  deficient  renal  secretion,  by  giving  diuretics— fluids  in 
small  and  off-repeated  doses,  the  diseased  genitals  will  often  improve   in 


RENAL   SECRETION   AFFECTED   BY   REFLEXES  213 

direct  proportion  to  the  increase  of  renal  secretion.  Deficiency  of  renal 
secretion  irritates  the  genitals  by  non-removal  of  urinary  solids.  Diseased 
genitals  irritate  the  kidneys  by  reflex  action.  This  is  all  accomplished 
through  the  abdominal  brain  as  a  center.  The  genitals,  kidneys  and  abdomi- 
nal brain  constitute  a  very  vital  triangle.  In  the  middle  of  its  base  lies  the 
significant  abdominal  brain  and  at  the  apex  the  important  genitals,  while  the 
other  two  angles  are  occupied  by  the  kidneys.  The  uterus  and  kidneys  have 
the  highest  nerve  and  blood  supply  of  all  viscera,  hence  they  experience 
more  profoundly  than  other  viscera  the  forces  which  are  organized  and 
reorganized  in  the  abdominal  brain.  In  the  sympathetic  nervous  system  the 
kidneys  play  a  vast  and  immeasurable  role.  If  by  some  irritation  in  the 
pelvis  or  abdomen  the  kidney  begins  to  secrete  insufficiently,  the  whole 
organism,  together  with  the  ganglionic  nervous  system,  or  the  cyclo-gang- 
lionic  system,  as  Solly  termed  it  half  a  century  ago,  will  become  poisoned 
from  non-elimination.  From  this  peculiar  reflex  action,  of  which  the  abdomi- 
nal brain  is  capable,  we  may  yet  learn  that  disease  of  the  pelvic  organs  of 
woman  may  be  cured  by  diuretics,  cathartics  or  diaphoretics.  In  other  words 
drain  the  skin,  drain  the  kidneys  and  drain  the  bowels.  The  intimate  and 
close  relations  of  the  genitals  and  kidneys  is  plain  anatomically  and  physio- 
logically, as  large  bundles  of  nerves  from  the  abdominal  brain  supply  both. 
Clinically,  then,  these  closer  relations  have  been  demonstrated  of  late  years, 
as  gynecology  has  progressed.  The  cyclo-ganglionic  system  is  recognized  as 
a  finely  balanced  mechanism  capable  of  prompt  response  when  once  its 
manifestations  are  understood. 

For  example,  no  one  understands  so  well  as  the  gynecologist  the  vital 
relation  which  exists  between  deficient  kidney  secretion  and  diseased  pelvic 
organs.  Effective  diuretics  relieve  many  pelvic  pains.  Baths  and 
diaphoretics  subdue  innumerable  neuralgias,  and  cathartics  disperse  dragging 
pains.  A  woman  may  have  a  sound  kidney  (so  far  as  chemical  examination 
of  the  urine  may  indicate)  and  yet  reflex  action  from  the  genitals  may 
induce  it  to  secrete  deficient  or  excessive  fluids  or  solids,  which  not  only 
further  disturbs  the  genitals  with  waste-laden  blood  but  disarranges  the  fine 
balance  in  other  viscera  with  the  same.  Wherever  this  waste-laden  blood 
advances  it  produces  new  points  for  reflex  irritation,  unbalancing  the  whole 
system.  It  seems  to  me  there  is  no  better  point  to  work  from  in  this  con- 
sideration than  the  relation  of  the  genito-urinary  system  to  the  abdominal 
brain.  Clinical  features  are  more  manifest  here  than  elsewhere.  Gynecol- 
ogists may  even  cure  women  of  innumerable  ailments  by  simply  inducing 
them  to  drink  water.  I  have  accomplished  much  for  women  during  the  past 
fifteen  years  by  inducing  them  to  drink  a  full  glass  of  water,  six  times  daily, 
containing  a  pinch  of  Epsom  salt  in  solution.  The  late  Dr.  J.  H.  Etheridge 
wrote  instructively  on  renal  secretion  in  gynecologic  patients. 

During  menstruation  girls  show  distinct  clinical  symptoms  of  pain  in  the 
region  of  the  kidneys,  and  of  variation  in  urinary  secretion,  showing  the 
close  relation  between  this  and  pelvic  disturbances.  It  is  clear  that  this  pain 
in  the  kidney  region  is  due  to  reflexes  from  the  menstrual  organs,  i.  e.,  the 
uterus  and  oviducts. 


214  THE  ABDOMINAL  AND  PELVIC  BRAIN 

The  kidney,  in  proportion  to  its  size,  has  the  highest  nerve  and  blood 
supply  of  any  viscus,  except  the  uterus.  According  to  the  recent  investiga- 
tions at  Johns  Hopkins  University,  the  kidney  is  supplied  only  by  sympathetic 
nerves.  It  is  a  common  observation  that  abdominal  tumors  are  followed  by 
kidney  disturbances.  Even  the  gravid  uterus  does  not  allow  the  kidney  to 
escape  irritation.  This  kidney  disease  brought  about  by  abdominal  tumors 
is  reflex.  It  is  a  physiological  principle  that  an  influence  acting  through  the 
nerves  alone  can  arrest  all  secretion.  Minor  degrees  of  irritation  will  suffice 
to  increase,  diminish  or  change  the  kidney  secretions.  Irritation  of  an  organ 
continued  indefinitely,  and  modifying  its  action,  may  be  sufficient  to  induce 
disease.  Kidney  disease  resulting  from  abdominal  tumors  is  chiefly  chronic 
from  the  very  nature  of  the  case. 

The  first  point  to  consider,  as  the  initial  step  in  chronic  renal  disease 
from  abdominal  tumors,  is  partial  or  complete  obstruction  to  the  flow  of 
urine. 

The  second  point  to  consider  in  chronic  renal  disease  due  to  abdominal 
tumors  is  reflex  irritation  from  distant  viscera. 

The  third  point  of  consideration  is  infection. 

As  regards  the  first  point,  obstruction,  the  location  and  size  of  the  tumor 
may  be  noted.  A  partially  occluded  ureter,  through  long-continued  pressure, 
will  cause  renal  disease.  Under  this  head  would  be  classed  mechanical 
impediments  to  the  flow  of  urine.  If  the  obstruction  is  sufficient  it  will 
create  hydroureter.  If  the  hydroureter  is  long  enough  maintained  the  kidney 
will  secrete  until  blood  pressure  is  impaired,  and  then  in  a  few  months 
atrophy  will  follow.  The  writer  has  proved  by  experiments  on  the  dog  that 
when  the  ureter  is  completely  ligated,  the  kidney  will  shrink  to  about  one- 
fifth  its  original  size,  in  five  months. 

The  pressure  of  the  tumor  on  the  ureter  is  a  silent  process  not  often 
recognized  by  the  attendant.  The  obstruction  of  the  ureter  is  like  the 
quietly  growing  intestinal  stricture,  which  is  rarely  recognized  until  some 
terrible  disaster  reveals  a  long  series  of  old  pathological  conditions.  The 
main  idea  in  the  obstruction,  however,  is  that  it  is  partial,  and  by  raising 
the  difficulty  of  urine  flow,  renal  elminiation  becomes  deficient.  The  blood 
then  becomes  waste-laden.  If  the  obstruction  is  sufficient,  the  result  will  be 
hydroureter,  which  being  long  continued  (without  infection)  results  in  renal 
atrophy,  as  the  writer  proved  by  tying  the  dog's  ureter. 

The  second  point,  reflex  irritation,  is  more  significant,  because  it  means 
that  irritation  from  any  viscus  can  be  reflected  to  the  kidney,  over  the  renal 
plexus.  The  abdominal  tumor  irritates  some  contiguous  viscus;  this  irrita- 
tion quickly  passes  to  the  abdominal  brain,  by  way  of  the  sympathetic 
plexus  of  said  viscus,  where  the  forces  are  reorganized  and  transmitted  to 
the  kidney.  There  is  little  doubt  that  the  rise  of  temperature  from  passing 
a  sound  into  a  man's  bladder  is  due  to  reflex  irritation  transmitted  from  an 
oversensitive  urethra.  It  is  probable  that  the  so-called  urinary  fever  is  reflex. 
It  modifies  circulation  by  inducing  local  anemia  and  local  hyperemia.  In 
this  way  nutrition  quickly  changes.       Examples  may  be  seen  in  strictures  of 


REFLEXES   AFFECT  SFCRETIOXS  215 

the  intestine  or  ureter  where  the  walls  above  the  stricture  are  greatly 
thickened. 

The  chief  point  in  regard  to  secretions  in  patients  with  abdominal 
tumors  is  a  decreased  or  disproportionate  secretion.  It  is  common  to  observe 
a  patient  with  a  tumor  secreting  a  small  quantity  of  urine  heavily  laden  with 
salts.  The  amount  of  urine  voided  at  times  appears  as  an  alarmingly  small 
quantity.  Natural  reasoning  from  clinical  and  physiological  bases  attributes 
the  decreased  quantity  of  urine  to  the  irritation  from  the  tumor  transmitted 
over  the  renal  plexus.  Autopsies  on  women  who  die  of  tumors  prove  it 
beyond  the  shadow  of  a  doubt. 

Disproportionate  renal  secretion  from  the  irritation  of  abdominal  tumors 
is  also  common.  Albumen  is  the  chief  element  found.  But  phosphates, 
urates  or  sugar  make  up  the  varying  scales  of  salts.  Even  the  amount  of 
water  will  vary  within  wide  limits. 

The  tumor  of  pregnancy  is  a  common  example  of  disturbed  renal 
secretion  due  to  reflex  action.  Thus  deranged  renal  secretion  is  frequently 
due  to  reflex  irritation,  depending  on  the  presence  of  an  abdominal  tumor. 
The  change  in  the  secretion  consists  in  increase,  decrease  or  disproportionate 
quantities.  As  each  organ  has  its  own  distinct  nerve  plexus,  so  it  should  be 
understood  that  reflex  action  is  carried  along  distinct  anatomical  lines. 

As  regards  the  third  point,  infection,  in  chronic  renal  diease  from  the 
presence  of  abdominal  tumors  a  serious  condition  appears. 

The  genito-urinary  tract  can  be  infected  at  any  point  from  the  kidney 
cortex  to  the  urethral  end.  If  the  tumor  presses  severely  enough  on  the 
urinary  tract,  a  perforation  will  occur,  and  from  this  perforation  infection 
will  travel  in  either  direction — toward  the  urethra  or  toward  the  kidney. 

The  result  of  perforation  of  the  urinal  tract  will  be  nephritis  and  cystitis. 
The  perforation  is  most  likely  to  occur  in  the  bladder,  from  which  the  infec- 
tion ascends  the  ureters  to  the  kidney.  It  is  not  necessary  to  have  a  large 
tumor  to  perforate  the  urinal  tract ;  simply  a  suppurating  focus  is  sufficient. 
It  is  not  necessary  to  have  a  complete  perforation  of  the  urinary  tract  to  allow 
infection  to  gain  an  entrance,  for  the  germs,  or  their  products  (ptomaines), 
may  penetrate  a  thin  pathological  wall.  The  final  result  of  an  infected 
urinary  tract  is  ureteritis,  with  parenchymatous  or  interstitial  nephritis.  The 
writer  has  observed  some  disastrous  results  from  pyosalpinx  perforating  the 
bladder  and  intestines.  It  may  here  be  noted  that  Doran,  a  most  excellent 
observer,  made  post-mortem  examinations  of  forty  women  who  had  died  of 
ovarian  tumors,  and  thirty-two  had  severe  kidney  disease.  This  means  that 
80  per  cent,  of  those  who  died  from  ovarian  tumors  had  kidney  disease.  No 
doubt  the  kidneys  were  diseased  from  the  presence  of  tumors.  Obstruction, 
reflex  action  or  infection  was  the  causative  factor  of  renal  disease,  resulting 
from  pressure  of  tumors. 

A  good  sample  of  obstruction,  reflex  irritation  and  infection  of  the 
urinal  tract  is  seen  in  cases  of  gonorrhea  in  men  which  end  in  stricture  and 
"catheter  life."  The  stricture  generally  arises  in  the  urethra  and  marks  the 
onset  of  obstruction  to  the  urinary  flow.     This  increasing  obstruction  induces 


216  THE  ABDOMINAL  AND  PELVIC  BRAIN 

constant  reflex  irritation,  and  yet  the  man  is  not  subjectively  or  objectively 
sick.  But  now  he  begins  "catheter  life,"  which  means  infection.  It  means 
self-destruction  by  his  own  hands.  Thus  to  obstruction  and  reflex  irritation 
of  the  urethra  he  has  added  the  fatal  infection  carried  on  his  catheter,  which 
too  frequently  makes  the  fatal  march  swiftly  onward  and  swiftly  downward. 

The  kidney  suffers  similarly  from  any  abdominal  tumor,  and  chiefly  by 
reflex  irritation,  which  passes  from  the  abdominal  brain  by  way  of  the  con- 
tiguous plexus,  where  it  is  reorganized  and  emitted  on  the  large  renal  plexus 
to  the  kidney.  The  writer  notes  that  those  women  who  come  to  him  for  the 
purpose  of  having  tumors  removed  have  a  very  variable  quantity  of  urea  in 
the  urine.  At  the  Woman's  Hosipal  the  writer  has  the  urea  tested  in  every 
case  of  laparotomy,  and  the  amount  varies  from  five  to  eleven  grains  to  the 
ounce.  The  tumors  appear  to  play  a  significant  role  in  the  production  of 
varying  quantities  of  urea. 

What  has  been  said  in  regard  to  kidney  disease  by  reflex  irritation  is 
equally  prominent  in  floating  or  excessively  movable  kidney.  The  dragging 
of  the  kidney  on  the  abdominal  brain,  through  the  renal  plexus,  unbalances 
the  viscera  very  distinctly.  The  patient  suffers  from  nausea,  from  constipa- 
tion, from  disturbed  secretion  and  circulation  and  from  dull  dragging  pains. 
The  patient  may  sometimes  suffer  similarly  from  an  artificially  fixed  kidney, 
as  I  have  observed  often  after  a  nephropexy  of  my  own,  when  viscera,  which 
are  normally  excessively  mobile  or  fixed,  are  dislocated,  they  lose  a  part  of 
their  physiology,  which  is  motion. 

Calculus  in  the  ureter  is  a  typical  sample  of  disturbance  in  the  sympa- 
thetic nerves.  One  of  my  patients  was  idle  ten  months  before  I  removed  a 
ureteral  calculus,  and  she  suffered  from  an  unblanced  sympathetic  nervous 
system  just  as  a  woman  would  from  diseased  genitals. 

Abdominal  and  pelvic  tumors  produce  disease  in  the  digestive  tract. 
Object  lessons  are  not  only  impressive  to  children,  but  to  adults.  The 
wonder  is  how  the  visceral  organs  can  adapt  themselves  to  growing  and 
movable  tumors.  To-day  we  removed  an  ovarian  tumor  the  size  of  a  child's 
head  with  a  narrow  pedicle  of  seven  inches.  The  tumor  could  be  pushed 
into  almost  any  position  of  the  abdomen.  Yet  this  tumor,  which  the  patient 
has  had  for  about  ten  months,  appears  to  have  told  on  her  health.  To  be 
sure  it  glided  where  it  would  without  any  apparent  trouble,  but  doubtless 
the  continued,  repeated  and  accumulated  traumas  on  the  other  viscera  main- 
tained a  constant  story  of  visceral  insult.  Every  step  she  took  induced  the 
tumor  to  jog  and  roll  around  in  the  abdomen.  Occasionally  it  would  become 
partially  wedged  in  the  pelvis,  producing  congestion  and  disturbed  circulation 
and  insults  to  the  delicate  nerves  of  the  peritoneum.  This  solid  tumor  was 
not  like  the  yielding,  soft  viscera;  but  wherever  it  would  lie  it  pressed  and 
disturbed  circulation.  It  is  probably  true  that  smaller  tumors  of  the  pelvis 
and  abdomen  produce  much  more  traumatic  visceral  insult  than  larger  ones 
which  move  but  little.  The  real  wonder  was  that  such  a  tumor  as  the  above 
could  glide  about  among  the  mobile  viscera  so  long  and  not  become  rotated 
on  its  axis. 


REFLEXES  ALTER  GLAND  SECRETIONS  217 

It  is  probable  that  secreting  or  glandular  organs  suffer  the  most  from 
abdominal  tumors,  because  the  main  damage  is  through  reflex  action,  and  the 
glands  are  the  most  highly  supplied  with  sympathetic  nerves.  The  digestive 
tract  should  be  studied  by  means  of  (a)  sensation,  (b)  motion,  (c)  secretion, 
(d)  absorption.  The  slow,  continuous  pressure  of  abdominal  tumors  pro- 
duces but  little  recognizable  sensation  in  the  digestive  tract.  Another  point 
is  that  from  inexperience  the  patient  cannot  localize  the  pain  in  the  digestive 
tract,  but  refers  it  mostly  to  the  abdominal  brain;  so  that  the  subjective 
sensation  in  the  digestive  tract,  due  to  tumors,  is  of  small  value.  As  regards 
motion  in  the  digestive  tract,  in  cases  of  abdominal  tumors,  one  can  say  that 
in  the  great  majority  of  fair  or  large-sized  tumors  motion  is  diminished  and 
constipation  is  the  rule.  But  the  main  study  of  damage  of  abdominal  tumors 
in  the  digestive  tract  will  be  through  the  secretions.  Secretions  are  altered 
in  three  ways:  (a)  they  may  be  excessive,  (b)  decreased,  or  (c)  dispropor- 
tionate. 

The  final  result  is  indigestion.  The  irritation  from  the  tumor  is  carried 
on  the  plexus  of  any  contiguous  viscus  to  the  abdominal  brain,  where  it  is 
reorganized  and  emitted  to  the  digestive  tract  over  the  gastric  plexus,  the 
superior  mesenteric  plexus  and  the  inferior  mesenteric  plexus.  In  any  case 
the  brunt  of  the  forces  ends  in  the  ganglia  which  lie  just  below  the  mucous 
membrane;  the  ganglia  constitute  what  is  known  as  Meissner's  plexus,  which 
rules  secretion. 

If  the  irritation  be  of  such  a  nature  as  to  produce  excessive  secretion, 
diarrhea  may  result.  The  excessive  secretions  will  decompose,  ferment,  and 
induce  malnutrition.  It  is  common  to  observe  in  women  with  tumors,  spells 
of  indigestion,  and  especially  in  times  of  excessive  irritability.  No  doubt  at 
such  times  the  irritation  assumes  a  prominence  not  experienced  on  other 
occasions.  If  the  irritation  is  of  such  a  nature  as  to  diminish  secretion,  con- 
stipation will  likely  result.  An  inactive  digestive  tract  is  the  forerunner  of 
non-elimination  and  a  waste-laden  blood.  It  is  common  to  observe  anorexia 
for  weeks  at  a  time,  accompanied  by  constipation,  in  women  who  have 
tumors.  No  doubt  the  main  chapter  in  altered  secretion  consists  in  what 
may  be  termed  disproportionate  secretion.  The  elements  which  make  up 
the  digestive  fluid  are  not  secreted  in  normal  quantities;  one  element  is 
deficient  and  the  other  is  excessive.  The  normal  relations  of  acidity  and 
alkalinity  are  changed  so  that  constant  fermentation  arises.  Again,  from  the 
irritation  of  an  abdominal  tumor,  individual  organs  do  not  secrete  their  nor- 
mal quantity  or  quality. 

The  liver  may  secrete  excessively  or  deficiently.  The  pancreas  may  do 
too  much  or  too  little.  The  irritation  may  cause  segments  of  the  alimentary 
canal  to  secrete  excessively  or  deficiently  and  thus  destroy  the  finely  balanced 
secretion  of  the  canal  as  a  whole.  The  stomach  enteron,  small  intestines, 
may,  by  the  irregular  irritation,  do  too  much  or  too  little,  or  act  irregularly. 
This  produces  decomposition  in  the  fluid  and  fermentation  results.  Such 
women  are  continually  troubled  with  "wind  on  the  stomach."  Diarrhea  and 
constipation  quickly  alternate  and  the  result  is  frequent  attacks  of  acute 
indigestion. 


218  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

Disproportionate  secretion  is  the  most  frequent  and  disastrous,  because 
the  irritation  from  the  tumor  is  irregular.  It  storms  one  day  and  sleeps  the 
next.  But  the  nature  of  irritation  is  to  be  inconstant  and  to  rush  pell  mell 
over  the  nerve  [plexuses,  or  to  assume  a  profound  quietude.  Irritation 
scampering  over  the  plexuses  month  after  month  is  sure  to  be  followed  by 
indigestion,  malnutrition,  anemia;  and  the  final  ending  of  the  poor  patient 
is  neurosis. 

The  subject  of  pressure  cf  abdominal  tumors  on  the  digestive  tract  may 
here  be  considered.  The  effect  of  pressure  acts  in  two  directions:  (a)  on  the 
alimentary  canal  and  (b)  on  the  tumor  itself.  The  effect  on  the  canal  may 
be  (a)  to  derange  the  secretion  and  motion  of  the  segment  pressed  on;  (b)  to 
perforate  the  canal;  (c)  to  obstruct  the  canal.  The  more  serious  effect  of 
the  tumor  pressure  on  the  digestive  tract  arises  from  the  changes  which  result 
in  the  tumor  itself.  The  changes  arising  in  the  tumor  from  the  alimentary 
canal  are:  (a)  inflammation,  (b)  adhesion,  (c)  suppuration  and  (d)  rupture. 
The  main  idea  is  that  infection  or  its  product  (ptomaines)  enters  the  tumor 
through  the  gut  wall. 

It  frequently  happens  in  laparotomy  that  some  part  of  the  digestive  tract 
is  firmly  adherent  to  the  tumor.  The  cause  of  this  adhesion  is  the  formation 
of  exudates  into  organized  tissue  which  binds  the  intestinal  wall  and  tumor 
together.  The  irritation  from  the  contact  of  the  intestinal  wall  and  tumor 
induces  the  passage  of  germs  or  their  products  (ptomaines)  through  the  wall 
of  the  intestine,  which  gives  rise  to  an  exudate.  The  writer  has  fully 
satisfied  himself  that  considerable  inflammation,  adhesion  and  suppuration, 
which  are  found  to  exist  in  tumors,  are  due  to  the  passage  of  the  morbid 
matter  through  the  intestinal  canal.  It  is  not  uncommon  for  one  to  find 
from  an  inch  to  a  foot  of  intestine  firmly  attached  to  a  tumor,  when  the  great 
gateway  of  infection,  the  oviducts,  show  no  traces  either  ancient  or  recent. 
The  vermiform  appendix  is  a  certain  source  of  infection,  not  only  in  abdomi- 
nal tumors,  but  also  of  the  genital  organs. 

Considerable  inflammation  and  adhesion  of  intestines  (and  occasionally 
of  other  organs)  when  abdominal  tumors  exist  is  accounted  for  by  infection 
passing  through  the  intestinal  wall  into  the  tumor.  As  regards  suppuration 
in  abdominal  tumors,  due  to  infection  arisirg  from  the  alimentary''  canal,  it 
may  be  said  that  it  is  only  a  stage  in  advance  of  inflammation,  and  that 
inflammation  is  only  a  degree  short  of  suppuration.  So  that  in  one  sense 
they  are  the  same  process.  In  the  case  of  inflammation,  the  white  blood- 
corpuscles  have  conquered  the  invaders  and  resisted  further  progress;  while 
in  suppuration  the  invading  infection  destroys  whole  fields  of  vital  tissue, 
leaving  focuses  of  local  death — necrosis.  The  pus  formed  by  these  infections 
through  the  intestinal  wall  may  be  safety  evacuated  by  way  of  the  alimentary 
canal.  But  frequently  fatal  issues  follow  either  rapidly  or  through  long 
exhausting  processes. 

The  sympathetic  pathological  course  which  abdominal  tumors  induce 
in  women  are:  (1)  irritation,  (2)  indigestion,  (3)  malnutrition,  (4)  anemia, 
and  (5)  neurosis.     The  irritation  passes  by  reflex  action  to  the  digestive  tract 


AXIAL  ROT  ATI  OX   OF   TUMORS  219 

(including  the  liver  and  pancreas).  The  irritation  destroys  in  the  digestive 
tract  (a)  the  rhythm  of  the  liver,  pancreas  and  alimentary  canal  by  emitting 
irregular  forces  over  the  plexuses  at  irregular  periods  (the  reflex  action  has 
no  regard  for  rhythm);  (b)  the  irritation  produced  by  the  tumor  on  the  canal 
destroys  its  motion;  (c)  it  destroys  its  sensation;  (d)  it  destroys  its  normal 
secretion  ;  (e)  it  destroys  absorption. 

Indigestion  is  a  natural  result  of  imperfect  rhythm,  motion,  sensation, 
absorption  and  secretion  of  the  alimentary  canal.  Long  continued  indiges- 
tion results  in  malnutrition;  which  finally  ends  in  anemia.  In  anemia  the 
fluid  tissue  known  as  blood  is  proportionately  deficient  in  its  constituents, 
and  the  innumerable  nerve  ganglia  being  bathed  in  waste-laden  and  impover- 
ished blood,  the  woman  is  finally  reduced  to  an  irritable  condition,  or 
neurosis. 

One  of  the  strange  features  of  abdominal  tumors  with  long  pedicles  is 
that  so  few  rotate  on  their  axes.  In  autopsies  I  have  noted  the  spleen  resting 
on  the  pelvic  floor  with  a  long,  narrow  pedicle,  but  no  symptoms  of  rotation. 
Dr.  Lucy  Waite  and  I  have  removed  tumors  with  astonishingly  long  and  thin 
pedicles  with  no  symptoms  of  present  or  past  axial  rotation.  Dr.  Orville 
MacKellar  and  I  removed  an  ovarian  tumor  about  the  size  of  a  year-old  child's 
head  with  a  thin  pedicle  about  eight  inches  long,  with  no  symptoms  of  past 
or  present  rotation.  We  could  push  the  tumor  all  over  the  abdomen  from 
the  pelvic  floor  to  the  diaphragm.  We  observed  the  long-pedicled  tumor  roll 
about  among  the  loose  intestines  after  opening  the  abdomen,  and  wondered 
why  its  pedicle  did  not  twist. 

However,  I  have  removed  tumors  which  had  no  pedicle.  They  had  been 
twisted  off  their  pedicles  by  axial  rotation  and  had  assumed  new  beds,  which 
were  nourished  by  the  newly  formed  vessels  from  adjacent  viscera  and  tissue, 
especially  the  omentum.  It  is  a  significant  fact,  noted  by  all  practical  gyne- 
cologists, that  when  a  woman  acquires  a  tumor,  it  may  only  be  recognized,  she 
will  frequently  fret  and  chafe  under  it  until  she  becomes  nervous  and  irritable 
and  her  coolness  and  quiet  serenity  leave  her.  She  also  tires  easily  and  does 
not  sleep  well. 

Such  a  case  came  to  me  a  few  days  ago,  from  whom  Dr.  Lucy  Waite  and 
I  removed  an  orange-sized  ovarian  tumor  per  vaginam.  This  lady  I  treated 
seventeen  years  ago,  when  she  was  a  blooming,  vivacious  girl.  Some  ten  months 
ago  she  began  to  complain  of  ill-defined  symptoms.  A  general  practitioner 
treated  her  a  year  ago  and  examined  the  pelvic  organs,  but  failed  to  find  the 
tumor.  Finally,  she  and  her  husband  decided  to  consult  a  gynecologist,  and 
came  to  me.  In  eight  to  ten  months,  from  the  rotation  of  the  tumor,  her 
nervous  system  had  lost  its  fine,  even  balance  of  former  years.  She  slept 
poorly,  was  irritable,  appetite  was  poor,  and  she  was  easily  tired  out  and  had 
lost  all  her  old  vivacity.  It  was  all  due  to  reflex  action  from  a  large  orange- 
sized  pelvic  tumor.     The  disturbance  will  disappear  with  the  tumor. 

Abdominal  tumors  should  be  removed  on  account  of  danger  of  axial 
rotation.  The  literature  which  takes  note  of  a  tumor  rotating  on  its  axis 
covers  only  about  thirty  years.     Rokitansky,  of  Vienna,  was  among  the  first  to 


220  THE  ABDOMINAL  AND  PELVIC  BRAIN 

call  attention  to  the  subject.  The  writer  estimates  from  literature  and  observa" 
tion  that  about  8  per  cent,  of  ovarian  and  parovarian  tumors  rotate  on  their 
axes.  In  1891  Mr.  Tait  told  the  writer  that  he  had,  up  to  date,  sixty-two 
cases  of  rotated  tumors.  While  a  pupil  of  Mr.  Tait,  for  six  months,  the 
writer  saw  four  tumors  rotated  on  their  axes.  Almost  any  abdominal  or 
pelvic  tumor  may  rotate  on  its  axis.  The  writer  has  observed  in  an  autopsy, 
rotation  of  the  cecum  and  ileum  on  each  other  three-quarters  of  a  turn,  but 
insufficient  to  obstruct  the  cecal  current.  Volvulus  is  only  axial  rotation  of 
the  sigmoid  on  the  mesosigmoid.  In  the  intestinal  tract  volvulus  occurs  in 
the  sigmoid  flexure  in  60  percent,  of  cases;  in  30  per  cent,  at  the  cecum,  and 
in  10  per  cent,  in  the  small  intestine.  Axial  rotation  of  the  digestive  tract 
constitutes  about  1  per  cent,  of  all  intestinal  obstructions.  It  is  no  doubt 
due  to  a  fatless,  elongated  mesentery  (enteroptosis)  and  previous  constipa- 
tion. As  regards  the  causes  of  axial  rotation  of  abdominal  tumors,  the  writer 
is  convinced  that  it  is  due  to  visceral  rhythm. 

The  first  rotated  ovarian  tumor  I  observed  was  in  Prof.  Czerny's  clinic 
in  1884.     The  tumor  was  removed  with  fatal  issue. 

Any  viscus  which  possesses  an  elongated  attachment  may  rotate  more  or 
less  on  its  axis.  The  uterus  has  been  found  rotated  so  as  to  demand  opera- 
tion. My  assistant,  Dr.  A.  Zetlitz,  operated  on  a  patient  in  whom  the  uterus 
was  found  with  almost  a  full  rotation,  due  to  a  contracting  cicatrix  from  an 
old  inflammatory  attack.  The  kidney  can,  and  does,  rotate  on  its  axis, 
resulting  in  partial  or  complete  obstruction — the  obstruction  of  its  ureter 
causing  hydroureter  and  the  obstruction  of  the  renal  vein  due  to  twisting,  inter- 
fering with  circulation  and  nourishment.  It  is  possible  for  the  spleen,  in  cer- 
tain abnormal  conditions,  to  rotate  on  its  axis.  In  one  autopsy  I  found  the 
spleen  on  the  pelvic  floor  with  a  thin,  partially  rotated  pedicle. 

Axial  rotation  of  abdominal  tumors  may  be  partial  or  complete,  acute  or 
chronic.  An  acute  case  generally  acts  in  the  following  manner:  A  woman 
has  an  abdominal  tumor.  She  has  a  sudden  onset  of  pain;  she  will  perhaps 
vomit.  In  twenty-four  to  forty-eight  hours  the  abdomen  will  gradually 
enlarge.  If  it  enlarges  very  extensively,  the  patient  becomes  pale  and  faint. 
The  enlargement  is  the  result  of  (a)  the  obstruction  of  the  return'venous  flow 
from  the  tightness  of  the  twist  in  the  pedicle;  (b)  the  dilatation  of  the  veins 
in  the  tumor,  and  (c)  the  rupture  of  a  vein  in  the  tumor. 

The  rigid-walled  artery  is  difficult  to  occlude,  and  so  keeps  pumping  its 
stream  of  blood  into  the  tumor.  The  soft-walled,  easily  compressible  vein 
is  quickly  occluded  by  the  twist  in  the  pedicle,  and  so  all  or  nearly  all  the 
blood  pumped  in  by  the  artery  is  retained  in  the  tumor.  The  consequence 
is  a  sudden  abdominal  enlargement.  Of  course  a  woman  may  bleed  to  death 
into  her  own  tumor,  and  such  cases  are  on  record,  confirmed  by  autopsy. 
The  tumor  may  twist  so  much  on  its  pedicle  that  it  may  occlude  both  vein 
and  artery.  I  had  such  a  case  in  a  girl  twenty  years  old.  When  the  abdo- 
men was  opened  the  tumor  was  gangrenous.  It  may  rotate  so  vigorously  that 
it  will  be  entirely  twisted  off  or  severed  from  its  connections.  In  such  cases 
the  tumoi  acquires  nourishment  from  the  surrounding  viscera.     The  trauma 


AXIAL  ROTATION  TUMORS  221 

resulting  from  the  axial  rotation  induces  sufficient  irritation  to  produce  an 
exudate  on  the  surface  of  the  tumor.  This  exudate  undergoes  organization, 
acquiring  blood-vessels,  nerves  and  lymphatics  sufficient  to  nourish  the  tumor 
without  its  old  pedicle.  The  writer  saw,  with  Mr.  Tait,  one  tumor  sufficiently 
rotated  on  its  pedicle  to  occlude  the  vein  and  artery,  which  was  nourished 
by  innumerable  delicate,  newly  organized  processes  of  visceral  tissue. 

In  my  own  practice,  while  performing  laparotomy,  I  have  been  surprised 
to  find  a  dermoid  ovarian  tumor  the  size  of  a  cocoanut  entirely  without  a 
pedicle.  It  was  wholly  nourished  by  omental  adhesions.  The  patient  gave 
me  a  history  of  a  severe  attack  four  years  previous,  from  which  time  pain 
and  tenderness  continuously  clung  to  her.  My  attention  was  first  called  to 
axial  rotation  of  tumors  in  1884,  at  Heidelberg,  in  the  clinic  of  Professor 
Czerny.  One  day  a  middle-aged  lady  suddenly  appeared  in  the  clinic  who 
had  come  from  her  home  in  the  country  very  sick.  The  professor  put  her  on 
the  table  and  examined  her  carefully.  She  had  a  high  pulse  and  temperature 
and  a  dusky  countenance.  She  appeared  very  ill.  Professor  Czerny  said: 
"Gentlemen,  I  cannot  make  the  diagnosis.  I  will  examine  her  again  and 
perhaps  operate  tomorrow."  The  writer  anxiously  waited  until  the  next 
day,  when,  sure  enough,  the  woman  was  put  to  sleep  on  the  operating  table. 
On  opening  the  abdomen,  a  tumor  the  size  of  a  melon  appeared  in  the 
wound.  It  was  dark  red  in  color,  and  Professor  Czerny  pronounced  it  gan- 
grenous. It  was  easily  removed  and  its  pedicle  ligated.  That  was  a  cyst 
rotated  on  its  axis ;  and,  besides,  it  was  not  gangrenous,  as  such  tumors  rarely 
become  gangrenous  in  the  abdomen,  and,  if  washed  well,  will  show  the  color 
of  normal  tissue.  Gangrene  generally  comes  from  tapping  such  cysts,  or  the 
digestive  tract  may  infect  them.  Cases  have  been  frequently  recorded  where 
death  followed  tapping.  Intestinal  contents  entered  the  cyst  and  infection 
resulted. 

Axial  rotation  of  abdominal  and  pelvic  tumors  may  pursue  a  chronic  or 
slow  course.  In  such  a  tumor  diagnosis  is  very  difficult.  The  pain  in  such 
cases  will  be  almost  wholly  carried  by  the  sympathetic  nerve,  and  pain  due 
to  irritation  of  the  sympathetic  is  generally  a  dull,  heavy  ache.  It  is  a  drag- 
ging pain.  Cerebro-spinal  nerves  induce  sharp,  lancinating  pain.  So  that 
slow  axial  rotation  of  the  abdominal  tumors  will  be  accompanied  by  dull, 
heavy,  dragging  pain.  It  may  be  noted  that  whenever  there  is  more  than 
one  tumor  in  the  abdomen  the  chances  are  very  much  increased  for  axial 
rotation.  Pregnancy  enhances  axial  rotation  much  more  than  the  presence 
of  a  double  tumor,  because  the  uterus  empties  itself  suddenly,  and  just  after 
labor  the  tumor  is  apt  to  rotate.  The  writer  has  seen  Mr.  Tait  operate  on  a 
woman  six  weeks  after  delivery  for  an  abdominal  tumor  which  rotated  about 
three  times  and  a  half  on  its  pedicle.  She  was  quite  ill  from  delivery  until 
after  the  operation,  when  she  rapidly  recovered. 

In  my  practice  I  have  observed  axial  rotation  of  ovarian  tumors,  ileo- 
cecal apparatus,  sigmoid  flexure,  ovario — oviductal  apparatus  in  a  young  girl, 
with  rotation  of  uterus. 

The  strikingly  easy    manner  in  which  operators    speak  of  gangrenous 


222  THE  ABDOMINAL  AND  PELVIC  BRAIN 

tumors  in  the  abdomen,  with  recovery,  calls  for  objections.  Recovery  after 
gangrene  or  local  death  in  the  abdomen  is  extremely  rare.  What  is  usually 
called  gangrene  is  simply  tissue  filled  with  venous  blood. 

Now,  if  this  dark  tissue  is  removed  and  well  washed,  the  gangrenous  idea 
will  be  dispelled  by  the  frequent  appearance  of  normal  white  tissue.  Air 
must  in  some  way  get  to  a  tumor  to  admit  of  gangrene,  and  air  enters  by  (a) 
tapping,  (b)  digestive  tract,  (c)  genito-urinary  tract.  If  a  cyst  has  rotated 
sufficiently  to  twist  off  its  pedicle  and  become  nourished  by  adhesions  to 
adjacent  viscera  it  is  more  dangerous  than  the  original  tumor  on  account  of 
its  fixation  and  adhesions.  It  is  generally  more  liable  to  infection  from  the 
natural  channels,  from  its  more  extensive  vascular  connection.  A  tumor 
should  be  removed  from  its  liability  to  axial  rotation.  A  tumor  rotated  on 
its  axis  is  dangerous  to  a  patient  from  (a)  hemorrhage  into  the  cyst,  (b)  gan- 
grene, (c)  because  it  may  unduly  enlarge  from  filling  the  veins  of  the  tumor, 
(d)  it  may  become  fixed  by  adhesions  and  thus  endanger  the  viscera,  a  fixed 
tumor  being  more  dangerous  than  a  movable  one,  (e)  it  may  become  infected 
and  suppurate,  (f)  chronic  axial  rotation  may  exhaust  a  patient  by  pain,  (g) 
it  may  result  in  trauma  to  viscera  or  perforation  of  viscera  by  pressure. 

Abdominal  tumors  should  be  removed  on  account  of  the  danger  of 
rupture.  It  is  a  fact,  which  the  writer  has  definitely  observed,  that  tumors 
(ovarian  and  parovarian)  will  repeatedly  rupture  and  fill  in  the  living  woman. 
In  one  case  under  my  care  the  parovarian  cyst  repeatedly  ruptured  and  filled 
during  a  year's  personal  observation.  At  the  time  of  rupture  the  young 
woman  of  twenty-four  would  experience  a  sense  of  relief.  The  abdomen 
would  become  flattened  and  during  a  few  succeeding  days  she  would  urinate 
frequently  and  profusely.  Years  previously  the  writer  had  demonstrated 
that  if  a  dog's  peritoneal  cavity  was  filled  with  water  he  would  urinate 
profusely  for  two  or  three  days.  In  removing  ovarian  tumors  the  writer  has 
found  old  scars  where  such  cysts  had  ruptured  and  refilled.  The  rupture 
may  be  due  to  violence  or  the  continued  pressure  on  some  point  of  the 
tumor,  thinning  its  walls  so  that  leakage  occurs. 

A  rupture  of  non-infected  cyst  does  no  harm  to  a  woman,  but  when  a 
cyst  containing  infected  material  ruptures  in  the  abdominal  cavity  death  is 
almost  inevitable.  Hence,  such  tumors  which  menace  life  should  be  removed 
on  discovery.  Cystic  abdominal  tumors  are  apt  to  rupture  from  increase  of 
abdominal  pressure,  which,  being  sustained  for  a  long  time  on  single  points 
of  the  cyst,  either  thin  its  walls  so  that  they  will  leak,  or  rupture  them  by  any 
violence.  In  one  case  the  writer  removed  an  ovarian  tumor  which  gave  a 
distinct  history  of  rupture  one  year  previous.  A  distinct  scar  about  the  size 
of  a  fifty-cent  piece  was  found  on  the  cyst  to  tell  the  story  of  rupture. 
Abdominal  tumors  may  endanger  life  by  rupturing  into  hollow  viscera  as 
intestine,  bladder,  or  vagina.  From  such  rupture  infection  is  almost  sure  to 
follow.  The  worst  infection  follows  rupture  into  the  digestive  tract,  and  sec- 
ond into  the  bladder.  The  writer  has  removed  ovarian  tumors  with  success 
which  had  ruptured  into  the  digestive  tract  and  almost  destroyed  the  patient 
by  chronic  suppuration  and  exhaustion.     About  the  worst  of  such  tumors  are 


REFLEXES   FROM    TUMOR    PRESSURE  223 

ovarian  dermoids,  which  rupture  into  the  sigmoid  or  rectum,  for  they  make 
such  dangerous  adhesions.  The  two  cysts  may  press  so  hard  and  long  against 
each  other  that  the  walls  in  contact  will  fuse  and  the  rupture  will  occur  in 
the  fused  septum,  which  complicates  by  more  adhesions  and  size  of  tumor. 

The  pressure  occasioned  by  abdominal  tumors  demands  their  removal. 
A  tumor  pressing  for  a  long  time  against  a  gut  wall  may  thin  it  so  that  germs 
or  their  products  may  pass  into  the  tumor  and  infect  it.  Inflammation  fol- 
lows and  may  be  accompanied  by  suppuration.  But  pressure  must  be 
observed  to  take  place  in  two  directions,  viz.,  toward  the  tumor  and  toward 
the  viscus.  The  damage  from  pressure  in  the  abdominal  tumors  is  threefold : 
(a)  the  effect  of  pressure  on  viscera:  (b)  the  effect  of  pressure  on  the  tumor, 
and  (c)  the  effect  of  the  pressure  on  the  function  of  viscera,  both  remote  and 
distant.  This  last  idea  was  discussed  under  reflex  action.  It  was  shown 
how  abdominal  tumors  induced  hydroureter  by  partial  or  complete  occlusion 
of  the  ureters.  Tumor  pressure  will  even  induce  interstitial  and  parenchy- 
matous nephritis.  Three-fourths  of  women  long  possessing  abdominal 
tumors  have  kidney  disease.  The  tumor  may  press  on  some  segment  of  the 
digestive  tract  and  induce  obstruction  of  the  fecal  current,  either  mechanic- 
ally or  by  reflex  paralysis.  The  main  point  of  pressure  is  on  some  fixed  por- 
tion of  the  intestine,  the  rectum,  sigmoid  or  colon. 

The  canals,  ureter  or  intestine,  curiously  maintain  their  patency  for  a 
long  time  on  account  of  their  continual  dilatation  and  contraction.  The 
writer  has  seen  these  canals  entirely  surrounded  by  dense  tissues  of  tumors, 
but  a  distinct  tunnel  still  existed  through  the  tumor,  considerably  larger  than 
the  empty  collapsed  canal.  The  abdominal  tumors,  in  a  word,  by  pressure, 
induce  obstruction,  mechanically  or  by  reflex  irritation  (spasm  or  paralysis), 
and  should  be  removed.  The  continued  pressure  gives  rise  to  (a)  inflamma- 
tion, by  allowing  infection  to  travel;  (b)  the  inflammation  may  go  on  to 
suppuration  and  end  in  perforation,  internally  or  externally. 

The  effect  of  pressure  on  the  circulation  (vascularity)  is  very  apparent 
It  acts  mainly,  or  the  effect  is  more  evident,  on  the  great  venous  plexuses. 
The  hemorrhoidal  from  the  inferior  mesenteric  suffers  the  most,  as  many  of 
such  patients  have  hemorrhoids.  The  effect  of  the  pressure  on  the  plexus 
pampiniformis  is  also  plain,  as  also  on  the  vaginal  plexus  and  the  venous 
bulb  of  the  pudendum.  Areas  of  tissue  become  cedematous.  The  limbs 
swell.  The  pelvic  organs  suffer  the  main  brunt  from  mechanical  pressure, 
while  distant  organs  evidently  suffer  most  from  reflex  action.  The  effect  of 
mechanical  pressure  on  circulation  is  (a)  congestion,  (b)  oedema,  (c)  dilation 
of  veins  (hemorrhoids).  It  must  not  be  forgotten  that  since  the  sympathetic 
is  mainly  distributed  to  blood-vessels  the  reflexes  from  pressure|on  the  vessels 
are  effective  and  profound,  local  and  general. 

The  writer  has  noted  the  effect  of  tumors  on  the  color  of  the  skin  for  a 
long  time.  It  has  been  recognized  that  pigmentation  arises  mainly  from  the 
spleen.  Jastrowitz  started  the  view  that  the  spleen  was  the  source  of 
pigmentation,  by  dividing  the  sympathetic  plexus  going  to  the  spleen  on  the 
spiral  splenic  artery.     This  experiment  enhanced  pigmentation.     No  doubt 


224  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

the  liver  is  a  second  source  of  pigment,  from  the  fact  that  it  buries  red 
corpuscles,  and  pigmentation  is  very  noticeable  in  malaria  which  profoundly 
affects  the  liver  (and  spleen  also).  But  still  the  spleen  may  be  credited  with 
the  main  origin  of  pigmentation.  The  writer  has  noted  nearly  all  colors  of 
pigmentation  (brown,  black  and  yellow)  in  such  women,  especially  in  a 
woman  who  has  had  a  tumor  a  long  time.  The  author  saw  a  woman  last 
month  who  had  had  a  tumor  for  sixteen  years.  Her  color  was  a  deep  brown 
and  yellow,  with  patches  of  atrophied,  glistening  skin  interspersed.  The 
tumor  disturbs  the  rhythm  of  the  spleen.  The  spleen  is  capable  of  a  rhythm 
by  (a)  its  elastic  covering  of  peritoneum,  (b)  its  elastic  capsule,  (c)  by  the 
power  of  its  cells  to  enlarge  on  receiving  excessive  blood.  When  the  tumor 
irritates  the  splenic  plexus  it  destroys  its  rhythm,  and  hence  its  nourishment. 
The  nourishment  being  disturbed,  the  distribution  of  its  products— pigment — 
will  be  disturbed.  Irritation  induces  the  spleen  to  produce  excess  of  pigment. 
The  parts  of  the  body  most  intensely  pigmented  are  those  -exposed  to  air. 
Yet  the  pigmentation  is  general.  The  simplest  example  of  pigmentation  is 
observed  in  pregnancy,  which  is  generally  localized  in  the  genitals,  breasts 
and  linea  alba. 

But  abdominal  tumors  create  more  definite  and  general  pigmentation. 
The  pigmentation  is  effected  by  the  irritation  passing  to  the  abdominal  brain, 
where  it  is  reorganized  and  emitted  to  the  spleen. 

The  irregular  forces  coming  at  irregular  intervals  to  the  spleen  derange  its 
rhythm,  and  consequently  its  nourishment.  Pigmentation  is  the  result  of  a 
silent  process  accomplished  by  reflex  irritation,  and  shows  general  derange- 
ment of  the  visceral  economy.  It  is  merely  the  outward  manifestation  of 
profound  processes,  indicating  removal  of  the  offending  invader.  It  is  diffi- 
cult to  convince  physicians  that  a  laparotomy  is  really  demanded  to  remove 
adhesions.     Adhesive  bands  have  blood-vessels,  lymphatics  and  nerves. 

A  tumor  should  be  removed  because  of  its  danger  to  create  adhesions, 
but  after  they  have  formed  they  often  require  removal.  They  should  be 
removed  when  they  give  rise  to  pain,  when  they  distort  and  unbalance  the 
viscera.  They  may  occasion  obstruction  to  any  hollow  viscus.  They  may 
strangulate  some  viscus. 

Even  the  lungs  do  not  escape  the  evil  influence  of  the  presence  of  the 
abdominal  tumor.  The  disturbance  in  the  lung  is  mainly  due  to  reflex  irri- 
tation which  disturbs  the  rhythm  of  the  lungs. 

Abdominal  tumors  should  be  removed,  from  their  liability  to  become 
infected. 

The  question  may  be  asked,  How  does  an  abdominal  tumor  become 
infected  or  inflamed?  Tumors  frequently  become  infected,  as  is  easily 
attested  at  the  operation,  by  observing  adhesions — the  result  of  infection. 

The  great  highway  by  which  abdominal  tumors  become  infected  is 
through  the  oviducts.  Any  laparotomist  can  easily  see  that  inflammatory 
exudates  arise  at  the  fimbriated  ends  of  the  oviducts,  and  from  there  spread. 
The  infection  travels  by  natural  routes,  especially  along  mucous  channels. 
It  travels  particularly  through  the  left  oviduct,  because,  as  the  writer  has 
demonstrated,  the  lumen  of  the  left  tube  is  larger  than  that  of  the  right. 


TUMORS  LIABLE    TO  INFECTION  225 

The  second  great  highway  of  infection  of  abdominal  tumors  is  through 
the  digestive  tract.  Germs  or  their  products  pass  through  the  intestinal  wall 
at  pressure  points  and  infect  the  tumor. 

The  third  channel  of  infection  is  through  the  genito-urinary  tract.  A 
fourth  is  by  tapping,  allowing  air  to  enter.  The  table  presented  with  this 
article  will  show  at  a  glance  the  reasons  for  removing  abdominal  tumors: 

EFFECTS  AND  CONSIDERATIONS  FOR  THE    REMOVAL  OF  ABDOMINAL  PELVIC  TUMORS. 

Heart— 

1.  Irregularity. 

2.  Hypertrophy. 

3.  Fatty  degeneration. 
Lungs — 

1.  Disturbed  rhythm — asthma. 

2.  Catarrh — anemic,  hyperemic. 
Liver — 

1.  Disturbed  rhythm. 

2.  Disturbed  secretion. 

3.  Pigmentation. 

4.  Nerve  influence  can  check  all  secretion. 

(a)  Excessive  secretion. 

(b)  Deficient  secretion. 

(c)  Disproportionate  secretion. 
Kidney — 

1.  Nerve  impression  can  check  all  secretion. 

(a)  Excessive  secretion. 

(b)  Deficient  secretion. 

(c)  Disproportionate  secretion. 

2.  Reflex  irritation. 

3.  Obstruction  (hydronephrosis). 

4.  Infection.         (a)  Parenchymatous     inflammation. 

(b)  Interstitial  inflammation. 
Digestive  Tract — 

1.  Sensation. 

2.  Motion. 

3.  Secretion. 

4.  Pressure. 

5.  Absorption. 

(a)  Excessive  secretion. 

(b)  Deficient  secretion. 

(c)  Disproportionate  secretion. 

(a)  Inflammation. 

(b)  Suppuration. 

(c)  Perforation. 

(d)  Adhesions. 

15 


226  THE  ABDOMINAL  AND  PELVIC  BRAIN. 

Spleen — 

1.  Disturbed  rhythm. 

2.  Pigmentation. 
Bladder— 

1.  Pressure. 

2.  Perforation. 
3»  Cystitis. 

Inflammation — 

1.  Through  oviducts. 

2.  Digestive  tract. 

3.  Genito-urinary  tract. 

4.  By  tapping. 
Circulation— 

1.  Congestion. 

2.  CEdema. 

3.  Hemorrhoids 
Suppuration — 

1.  Infection. 

2.  Fistula. 

3.  Adhesions  peritoneal. 

SYMPTOMS. 

Axial  Rotation — 

1.  Due  to  visceral  rhythm. 

2.  Ten  per  cent,  of  ovarian  and  parovarian  tumors  rotate. 

3.  Pregnancy  and  other  tumors  enhance  axial  rotation. 

4.  Diagnosticated  by  sudden  pain  and  increase  in  size  of  abdomen. 
Rupture — 

1.  Sudden  changes  in  form  of  abdomen. 

2.  Diuresis. 

3.  Diarrhea. 

4.  Cystitis. 
Pressure — 

1.  Inflammation. 

2.  Infection. 

3.  Perforation. 

4.  Hydroureter. 

5.  Obstruction. 

6.  (Edema. 
Adhesions — 

1.  Induce  pain. 

2.  Check  peristalsis. 

3.  Cause  reflex  rhythm. 

4.  Disturb  secretion. 


CHAPTER   XIX. 

THE  ABDOMINAL  AND  PELVIC    BRAIN  WITH  AUTOMATIC    VIS- 
CERAL GANGLIA  WITH    REFERENCE  TO  SEXUAL  ORGANS. 

"Instinct  is  a  propensity  prior  to  experience  and  independent  of  instruction." — 
Paley. 

"Probability  is  the  rule  of  life." — Butler. 

At  this  point  I  desire  to  call  attention  to  the  following  points: 

1.  The  intimate  and  profound  connection  of  the  genito-urinary  organs 
with  the  sympathetic  (and  cerebro-spinal)  nervous  system. 

2.  Its  connection  with  the  rectum  and  relation  to  coition. 

3.  The  relation  of  the  pelvic  organs  to  *he  larynx  (voice) ;  the  fifth  (gan- 
glionic) cranial  nerve,  stomach  and  eyes. 

4.  Automatic  menstrual  ganglia. 

5.  The  menopause. 

Every  observing  physician  sees  a  close  connection  between  the  genital 
organs  and  the  nervous  system.  This  is  not  strange  when  one  considers 
existing  conditions  and  the  long-continued  effect  of  evolutionary  forces.  Of 
all  the  instincts  in  the  animal  race,  the  sexual  instinct  is  dominant.  This 
instinct  has  an  all-pervading  influence  in  every  species  of  animal.  It  governs 
their  actions.  It  forms  habits  in  their  lives.  It  induces  new  phases  of 
existence.  All  through  the  stages  of  animal  evolution,  every  other  instinct 
must  bend  to  the  sexual.  Physical  and  mental  forces  wonderfully  combine  to 
make  this  instinct  the  most  effectual  in  its  consummation.  The  sexual 
instinct  dominates  most  powerfully  the  males,  and  hence  the  physical  and 
mental  vigor  of  the  best  animals  in  the  race  survive.  The  cow  in  rut  is 
served,  from  sheer  physical  and  mental  vigor,  by  the  most  powerful  bull.  In 
herds  of  animals  the  sexual  instinct  dominates  most  vigorously  in  the  finest 
males,  and  the  weak  males  are  cast  aside  that  the  strong  ones  may  become 
the  parents. 

The  main  study  of  zoology  is  reproduction.  The  weapons  of  offense  and 
defense  possessed  by  males  are  primarily  to  cultivate  and  defend  the  sexual 
instinct.  The  horns  of  bulls,  the  powerful  heels  of  stallions,  the  eagle's  talons, 
and  the  claws  of  powerful  feet  are  the  weapons  to  defend  and  to  carefully 
cultivate  this  dominant  instinct  of  animal  life.  When  we  pass  to  man, 
the  sexual  instinct  is  rather  heightened  than  diminished.  But  in  man  it  is 
more  subtle;  secretly  in  the  depths  of  man's  mental  forces  lies  his  sexual 
instinct.  As  he  has  gained  the  ascendency  in  animal  life  by  his  mental 
activities,  in  this  light  alone  can  be  studied  his  sexual  instincts.  Thus  in  the 
lowest  form  of  physical  existence  sexual  instincts  dominate,  yet  in  the  higher 
forms  of  mental  existence  these  instincts  are  still  more  powerful. 

227 


228  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

From  such  premises,  patent  to  all  observers,  it  is  quite  obvious  that 
evolutionary  forces  have  through  long  ages  established  a  very  close  connec- 
tion between  the  nervous  system  and  the  genitals — the  organs  which  gratify 
the  sexual  instinct.  Forces  (mental  or  physical)  acting  through  eons  of  ages 
establish  definite  results.  The  increase  of  man's  intelligence  is  not  in  pro- 
portion to  the  increase  of  ganglion  cells,  but  by  the  increase  of  conducting 
cords.  Chicago  and  New  York  may  each  represent  a  ganglion  cell,  and  a 
single  railroad  may  represent  the  conducting  cord.  Now,  when  there  was  but 
one  railroad  between  New  York  and  Chicago,  little  business  could  be  done 
on  account  of  the  limited  amount  of  commerce  which  the  single  road  would 
accommodate.  Chicago  and  New  York,  as  the  ganglia  cells,  could  dispose  of 
far  more  business  than  the  single  road  would  transmit.  But  when  the  rail- 
roads multiplied  between  the  two  centers,  the  business  increased  just  in  pro- 
portion to  the  number  of  roads  or  conducting  lines.  Now,  ages  of  natural 
forces  have  established  numerous  lines,  and  vigorous  lines,  of  connection 
between  the  genitals  and  the  nervous  system.  The  facts  which  dissection 
show  are  positive  in  demonstrating  the  widespread  and  intimate  connection 
of  the  genitals  with  the  cerebro-spinal  and  sympathetic  system. 

The  ganglion  cells  can  receive  and  dispose  of  far  more  mental  work  than 
a  few  conducting  cords  can  transmit;  so  that  the  progress  and  advance 
toward  a  higher  nervous  system  and  a  higher  intelligence  is  an  increase  in  the 
conducting  cords  or  lines  to  transmit  intelligence  or  ideas.  Also  a  well 
developed  periphery  is  an  absolute  necessity  for  the  purpose  of  collecting 
ideas  for  transmission.  An  increasing  sensitive  periphery  is  required  to 
perceive  the  forces  and  comprehend  ideas  so  that  they  can  be  sent  to  the 
central  ganglion.  Now,  the  number  of  conducting  cords  which  attach  the 
genitals  to  the  nervous  centers  is  simply  enormous.  Besides,  the  nerve 
periphery,  situated  in  the  external  genitals,  is  highly  sensitive  and  highly 
developed,  so  that  it  quickly  perceives  and  quickly  transmits  the  slightest 
sensation,  and  evolutionary  forces  through  the  ages  seem  to  increase  the 
sexual  instinct  with  the  progress  of  intelligence  and  mental  growth. 

I  base  these  remarks  on  years  of  careful  dissection  of  cadavers  and  of 
animals.  If  one  carefully  dissects  a  male  body  he  will  note  the  extensive 
cerebro-spinal  nerves  supplying  the  genitals,  especially  the  penis.  Of  the 
spinal  nerves  supplying  the  genitals,  the  main  one  is  the  pudic.  But  the 
pudic  nerve  is  composed  of  nearly  all  the  third  sacral,  and  branches  from  the 
second  and  fourth  sacral.  As  one  examines  this  nerve  he  is  forced  to  the 
conclusion  that  it  is  an  enormous  supply  for  a  small  organ. 

The  periphery  of  the  pudic  nerve  spreads  itself  like  a  fan  over  the  geni- 
tals. The  branches  of  this  fan-like  nerve-apparatus  supply  also  the  bladder 
and  rectum — organs  which  must  act  and  work  in  harmony.  Hence  the  great 
disturbance  which  arises  in  the  pelvis  (bladder,  rectum  or  genitals)  when  any 
one  organ  is  damaged — e.  g.,  a  rectal  fissure,  a  urethritis,  or  penile  irritation 
quickly  disturbs  the  whole  system.  The  connection  of  the  pudic  nerve  with 
the  external  genitals  (where  sensation  is  experienced)  is  vast.  Not  less 
remarkable  is  the  wonderfully  harmonious  action  of  the  bladder,  rectum  and 
genitals  through  large  branches  of  the  same  pudic. 


GENITALS   RICH    WITH  NERVES  229 

Another  peculiar  spinal-nerve  connection  of  the  external  genitals  is  the 
supply  of  the  pudendal  nerve  to  the  lateral  walls  of  the  penis.  I  have  time 
and  again  called  the  attention  of  medical  men  to  the  peculiar  connection 
between  the  gluteus  maximus  muscle  and  the  external  genitals  by  means  of 
the  pudendal  nerve  or  branch  of  the  lesser  sciatic.  The  gluteus  maximus  is 
the  real  muscle  that  holds  man  upright  (physically),  but  it  is  also  the  main 
muscle  of  coition.  The  lesser  sciatic  nerve  supplies  only  one  muscle,  and 
that  is  the  gluteus  maximus,  and  then  sends  off  the  large  pudendal  branch  to 
the  sides  of  the  penis,  and  hence  the  friction  of  coition  induces  active  con- 
tractions of  the  gluteus  maximus.  The  spinal-nerve  supply  to  the  external 
genitals  is  mainly  the  large  pudic  and  pudendal  nerves.  In  woman  the  pudic 
nerve  is  equally  large;  but  the  pudendal  nerve  is  much  smaller  in  woman 
than  in  man,  according  to  my  dissections.  The  lesser  size  of  the  pudendal 
nerve  in  woman  is  in  direct  accord  with  the  methods  of  cohabitation.  The 
vigorous  and  aggressive  activity  of  man  in  coition,  and  the  quiet  passive 
receptivity  of  woman,  explains  the  larger  pudendal  nerve  in  man.  But  the 
reverse  nerve  supply  arises  in  regard  to  the  glans  elitoridis  and  the  glans 
penis.  I  have  dissected  many  a  clitoris,  and  its  nerve  supply  is  three  or 
four  times  as  large  as  that  of  the  penis  in  proportion  to  its  size.  The 
clitoris  is  a  veritable  electrical  bell,  which,  when  irritated,  rings  up  the  whole 
nervous  system.  There  is  no  doubt  that  adhesions  of  the  prepuce  to  the 
clitoris  have  led  to  masturbation  in  girls.  Every  gynecologist  should 
examine  the  clitoris,  and,  if  preputial  adhesions  exist,  simply  break  them  up, 
for  the  vast  nerve  supply  of  the  clitoris  gives  great  chances  for  profound 
irritation.  The  poor  girl,  neglected  by  the  mother  and  possibly  by  the 
doctor,  is  soon  induced  to  become  a  masturbator. 

But  the  extensive  spinal-nerve  supply  to  the  external  genitals,  though 
vast  and  intimate,  is  but  a  small  matter  relative  to  the  supply  to  the  internal 
genitals.  The  spinal-nerve  supply  to  the  external  genitals  is  mainly  sensitive, 
so  that  the  sexual  instinct  may  be  gratified  by  the  organs.  What  I  wish 
mainly  is  to  call  attention  to  the  profound  connection  of  the  internal  genitals 
with  the  nervous  system  by  means  of  the  sympathetic  system.  It  is  in 
this  field  that  the  gynecologist  and  the  genito-urinary  surgeon  find  full  play 
for  lucrative  operations — for  so-called  aggressive  surgery.  In  manipulations 
and  instrumental  examinations  of  the  genitals  one  sees  the  nerve  storms  flash 
over  the  system.  These  nerve  storms  radiate  over  distant  nerve  plexuses 
like  electricity  over  a  system  of  wires.  Take,  for  example,  the  uterus.  Its 
sympathetic  nerve  supply  is  enormous.  The  cervix  only,  so  far  as  I  can  see, 
has  spinal  nerves,  while  the  body  and  fundus  are  supplied  by  the  sympathetic. 
One  can  count  some  twenty  or  thirty  strands  of  nerves  in  the  hypogastric 
plexus  which  originate  in  the  abdominal  brain  and  terminate  in  the  uterus, 
and  the  nerves  are  very  large.  The  ovarian  plexus — a  very  large  plexus — 
goes  from  the  abdominal  brain,  and  many  of  the  nerves  of  this  plexus  termi- 
nate on  the  oviducts  and  fundus  of  the  uterus  so  that  the  sympathetic  nerve 
supply  of  the  uterus  is  enormous.  A  large  nerve  supply  to  any  organ  sub- 
jects it  to  the  danger  of  sad  complications  and  stubborn  pathology.     I  have 


230  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

seen  a  patient  in  the  gynecological  chair  make  active  efforts  to  vomit  in  less 
than  fifteen  seconds  after  careful  introduction  of  the  sound.  In  those  few 
seconds  a  complicated  nervous  phenomenon  had  occurred.  The  irritation 
of  the  endometrium  had  been  flashed  up  the  hypogastric  plexus  to  the 
abdominal  brain,  and  there  it  was  reorganized  and  dashed  over  the  various 
plexuses  to  other  viscera. 

The  irritation,  no  doubt,  went  to  every  viscus  similarly,  but  the  stomach 
manifested  itself  in  motion  (vomiting).  The  heart,  lungs,  liver,  spleen  and 
digestive  organs  no  doubt  suffered  similarly,  but  the)7  were  better  able  to 
resist  the  irritation.  A  study  of  the  hypogastric  plexus  and  its  action  on  the 
uterus  convinces  me  that  pressure  on  the  aorta  for  post-partum  hemorrhage 
is  generally  explained  wrongly.  It  is  said  the  pressure  obstructs  the  blood, 
but  in  reality  the  pressure  on  the  hypogastric  plexus  irritates  the  peripheral 
ends  in  the  uterus,  and  induces  it  to  contract. 

This  is  more  reasonable.  The  dominating  influence  of  uterine  disease  is 
due  to  the  vast  and  intimate  connection  of  the  uterus  (oviducts  and  ovary) 
with  the  sympathetic  nervous  system.  Besides,  a  great  and  complicated  net- 
work of  nerves  is  easily  deranged.  The  importance  of  the  uterus  demands  a 
vast  and  complicated  nerve  supply.  It  may  be  laid  down  as  a  general  prop- 
osition that  the  viscera  have  their  normal  function  in  rhythm,  and  the 
disturbance  of  the  rhythm  induces  disease.  The  main  pathology  of  the 
sympathetic  is  reflex  action  from  some  distant  viscus. 

The  ganglia  controlling  the  viscera  are  entirely  out  of  the  control  of  the 
will.  If  the  visceral  movement  was  not  involuntary  or  out  of  the  mental 
sphere  men  would  speculate  and  experiment  on  their  viscera.  This  fact  no 
doubt  explains  the  curious  action  of  neurotic  women.  The  nerve  storms 
which  emanate  from  a  pathological  uterus  flash  over  the  whole  system  by  dis- 
tinct nerve  plexuses,  and,  as  the  will  does  not  control  any  of  such  reflexes, 
the  patient  acts  on  the  induced  feelings.  The  close  nervous  connection  of 
the  uterus  with  the  nervous  system  is  at  once  seen  in  the  great  changes  which 
uterine  disease  induces  in  both  the  mental  and  physical  life  of  a  woman. 
But  anatomical  facts,  physiological  experiment,  and  clinical  study  all  show 
that  the  genitals  and  nervous  system  are  more  highly  and  intimately  con- 
nected than  any  other  system.  No  organ  influences  a  woman  mentally  or 
physically  to  such  a  degree  as  the  uterus — the  autocrat  of  menstrual  life — 
even  in  its  normal  physiological  and  anatomical  condition,  while  its  patho- 
logical condition  is  still  more  manifest.  It  is  owing  to  the  very  distinct 
connection  of  the  genitals  with  the  cerebro-spinal  and  sympathetic  system. 
Let  a  woman's  genitals  become  pathological  and  she  acquires  liver  disease 
and  indigestion  and  becomes  anemic  and  neurotic.  Uterine  disease  also 
induces  eye  disease  and  heart  trouble,  and  the  joints  and  muscles  do  not 
escape.  Pelvic  diseases  are  often  accompanied  with  hip,  knee  or  ankle 
trouble.  This  is  no  doubt  due  to  the  intimate  connection  of  the  uterus  with 
these  joints  through  the  sacral  plexus;  e.  g.,  the  sacro-iliac  joint,  the  hip 
joint,  and  the  knee  joint  are  all  supplied  by  three  distinct  nerves — the 
great  sciatic,  the  anterior  crural,  and  the  obturator.     Now,  these  three  nerves 


GENITAL  NERVES  ABUNDANT  231 

are  really  the  sacral  plexus.  A  cold  contracted  at  the  monthly  period  from 
wet  feet  is  explained  no  doubt  by  close  connection  of  the  uterus  with  the 
sacral  plexus,  for  the  lower  end  of  the  sacral  (the  sciatic  nerve)  supplies  the 
feet.  The  disturbed  circulation  in  women  afflicted  with  uterine  disease 
is  owing  to  the  powerful  reflexes  sent  over  the  great  hypogastric  plexus, 
and  the  normal  rhythmical  contractions  of  the  heart  and  its  blood-vessels 
are  broken  by  reflex  due  to  uterine  disease. 

But  it  is  not  the  woman  only  who  is  afflicted  with  reflexes  from  the 
genitals.  The  genito-urinary  surgeon  who  deals  with  men  afflicted  with 
urethral  disease  knows  the  effect  often  of  the  mere  introduction  of  a  sound 
into  the  bladder.  A  healthy  man  will  frequently  faint  from  the  introduction 
of  a  sound,  and  if  the  urethra  or  genitals  are  long  diseased  he  will  be  pro- 
foundly shocked.  This  means  that  the  urethra  is  extraordinarily  supplied  with 
nerves.  I  do  not  see,  so  far,  any  better  explanation  of  so-called  urinary 
fever  after  the  introduction  of  a  catheter  than  that  it  is  "reflex."  The 
urethral  irritation  may  travel  in  two  ways  and  act  in  two  ways:  (1)  It  may 
travel  up  the  spinal  cord,  to  the  heat  center  either  by  the  sacral  plexus 
through  the  cord  or  by  the  splanchnics  through  the  cord  and  thus  disturb 
the  heat  center.  (2)  But  more  probably  the  urethral  irritation  is  trans- 
mitted up  the  hypogastric  plexus  to  the  abdominal  brain  and  is  reor- 
ganized and  emitted  on  the  various  plexuses. 

It  travels  on  the  renal  plexus  more  vigorously,  owing  to  the  more  inti- 
mate connection  existing  between  the  kidney  and  the  genitals — e.  g.,  the 
ureter  has  a  plexus,  the  testicle  has  a  plexus,  and,  also,  a  part  of  the  hypo- 
gastric plexus  forms  part  of  the  renal  plexus;  furthermore  the  kidney  and 
genitals  originally  arose  from  the  same  body — the  Wolffian. 

Now,  the  reflex  irritation  induced  by  the  catheter  on  the  urethra  then 
flashes  up  the  hypogastric  plexus,  and  the  reorganized  forces  are  sent  to  the 
kidney  and  the  irritation  acts  on  the  kidney  to  change  its  circulation ;  it  is 
congested  and  urinary  fever  follows.  The  fainting  of  patients  on  the  intro- 
duction of  a  catheter  is  explained  on  the  same  principle.  The  high  nerve 
supply  to  the  urethra  being  disturbed,  the  irritation  is  transmitted  to  the 
abdominal  brain,  where  it  is  reorganized.  The  reorganized  forces  are  then 
radiated  on  the  various  sympathetic  splanchnics  to  the  three  cervical  ganglia 
and  are  then  transmitted  by  their  three  nerves  to  the  heart,  which  is  induced 
to  move  in  a  riotous  manner.  The  heart  is  weakened  and  the  patient  faints. 
The  irritation  of  the  genitals  being  sent  to  the  abdominal  brain,  it  induces 
dilatation  of  the  abdominal  visceral  circulation,  and  this  probably  explains 
the  rise  of  temperature.  Occasionally  the  introduction  of  a  sound  kills  a 
patient,  but  that  may  be  due  to  the  weakness  of  the  patient  after  a  long-con- 
tinued exhausting  disease.  Thus  the  nerve  storms  arising  from  the  genitals 
are  entirely  due  to  the  abundant  and  exhausting  nerve  supply.  The  irregular 
nerve  storms  arising  in  genitals  highly  supplied  by  nerves  are  profound  in 
their  invasion  of  the  whole  system.  They  pervade  all  active  organs  and 
disturb  rhythm  and  induce  further  reflexes.  Reflex  action  from  the  sympa- 
thetic explains  much — e.  g.,  when  a  man  begins  the  "catheter  life"  he  rings 


232  THE  ABDOMINAL  AND  PELVIC  BRAIN 

his  own  death  knell;  by  the  use  of  the  catheter  he  induces  reflexes  which 
will  remorselessly  follow  him  until  death.  Besides,  he  introduces  infection 
into  the  urethra  and  kidneys  by  the  dirty  catheter. 

Thus  the  man  goes  through  three  stages  on  his  road  to  the  grave:  (1)  He 
has  acquired  some  form  of  obstruction  to  the  outflow  of  urine  from  kidney 
to  penis;  (2)  he  introduces  the  catheter,  which  calls  up  the  wide  domain  of 
reflexes;  (3)  he  introduces  infection,  and  death  follows.  If  the  genitals  were 
not  so  highly  supplied  by  nerves,  the  terrible  reflexes  would  not  arise.  As  an 
application  of  the  extensive  supply  of  sympathetic  nerves  to  the  genitals  and 
its  wonderful  reflexes,  examine  for  a  moment  the  result  of  coition. 

The  role  played  by  the  vaso-motor  centers  should  not  be  lost  sight  of. 
I  have  found,  time  after  time,  that  the  ganglia  of  the  lateral  chain  of  the 
sympathetic,  situated  at  the  root  of  the  pudic  (third  sacral),  were  very  large, 
and  this  will  aid  in  transmission  of  irritation. 

Conclusions.  1.  The  sexual  instinct  is  the  most  dominant  instinct  of 
animals. 

2.  Evolutionary  forces  have  linked  the  abdominal  sympathetic  nervous 
system  and  the  genitals  by  numerous  and  intimate  bands  which  increase  with 
the  progress  of  higher  development — i.  e.,  sexual  instincts  dominate  and 
influence  man,  as  well  as  the  monkey  and  the  ape,  far  more  than  the  lower 
grades  of  animals. 

3.  By  reason  of  the  growing  and  increasing  intimate  relations  between 
the  genitals  and  the  nervous  system,  mental  forces  play  a  greater  role  in  the 
production  of  disease. 

4.  I  have  observed  that  the  monkey  is  an  inveterate  masturbator  in 
confinement,  and  his  persistent  attention  to  the  genitals  shows^that  the 
sexual  instincts  keep  pace  with  mental  progress. 

5.  The  severe  shock  arising  from  hysterocotomy  shows  that  the  uterus 
has  an  extensive  nervous  connection  with  the  abdominal  brain.  In  this 
operation  one  severs  the  great  hypogastric  plexus,  and  I  have  seen  an  alarm- 
ing rise  of  temperature  (103°  F.),  disturbed  respiration  and  circulation,  all 
from  cutting  the  hypogastric  plexus.  The  disturbance  was  not  due  to  infec- 
ttion,  as  almost  all  of  it  arose  a  few  hours  after  the  operations.  Occasionally 
removing  the  appendages  shocks,  but,  as  the  ovarian  plexus  is  small,  the 
shock  is  limited. 

6.  The  genital  and  the  urinary  organs  both  arise  from  the  Wolffian  body, 
so  they  are  anatomically  and  physiologically  connected,  and  both  have  an 
enormous  nerve  supply,  so  that  damage  to  one  often  injures  the  other  by 
reflex — e.  g.,  hysterectomy  has  caused  death  by  inducing  nephritis  a  few  days 
succeeding  the  operation,  the  test-tube  revealing  three-quarters  albumin 
under  the  heat  test. 

7.  The  close  connection  between  the  genitals  and  nerve  system  is 
clearly  seen  from  the  terrible  nerve  storms  which  flash  over  the  system  from 
irritation  (manual,  instrumental  or  pathological)  of  the  genitals — e.  g., 
irritation  of  the  clitoris  quickly  disturbs  the  whole  nerve  balance. 

8.  The  great  nerve  connection  of  genitals  and  centers  indicates  that  all 


GENITAL    IRRITATION    CREATES   REFLEXES  233 

irritation  should  be  at  once  removed.  All  preputial  adhesions  on  the  clitoris 
should  be  broken  up,  and  the  same  with  those  of  the  prepuce.  In  short,  all 
pathological  conditions  of  the  genitals  should  be  at  once  righted,  so  that  the 
nerve  balance  may  be  maintained. 

The  reports  of  fainting  and  vomiting  and  even  death  during  coition  have 
a  scientific  interest  in  view  of  the  present  subject.  The  celebrated  Russian 
general,  Skobeleff,  died  while  cohabiting  with  a  woman  of  ill-fame.  Attila, 
king  of  the  Huns,  died  while  holding  sexual  relations  with  his  young  wife. 
In  a  small  town  in  Ohio,  a  man  nearly  70  years  of  age  was  reported  to  have 
died  during  coition.  Stock  men  have  made  interesting  reports  in  regard  to 
animals.  A  mare  put  to  a  stallion  fell  dead  at  the  end  of  coition.  Young 
male  animals  have  often  fainted  when  first  allowed  to  serve  the  female. 
The  dog  coition  is  prolonged,  which  limits  shock.  A  dog  has  no  semen  sacs. 
The  boar  has  an  intensely  violent  coition,  with  consequent  effect  on  his 
viscera,  as  in  respiration  and  circulation.  Young  stallions  are  the  most  lia- 
ble to  faint  of  any  of  the  domestic  animals.  Young  bulls  become  weak, 
exhausted  and  tremble  at  first  coition.  A  medical  acquaintance  related  to 
me  a  death  in  a  middle-aged  man  about  an  hour  after  coition. 

Dr.  Miller  related  two  instances  which  interested  him  very  much  because 
he  did  not  understand  the  explanation.  A  man  about  60  years  of  age, 
while  walking  to  the  door  a  few  minutes  after  cohabiting  with  a  strange 
woman,  fell  and  died  immediately.  In  another  case,  at  the  first  coition  the 
young  husband  fainted,  and  the  sphincters  relaxed,  defecation  and  urination 
resulting.  One  can  easily  observe  in  domestic  animals  that,  especially  in  the 
male,  the  respiratory  rhythm  is  disturbed — slowed  for  a  while  and  then 
quickened.  The  heart  will  also  be  disturbed  in  its  rhythm — slowed  for  a 
time  and  then  quickened.  The  explanation  of  these  phenomena  lies  in  the 
sympathetic  ganglionic  system.  The  vesiculae  seminales  are  very  highly 
supplied  by  the  hypogastric  plexus  of  nerves.  As  soon  as  the  irritation  is 
produced  on  the  nerves  of  the  semen  sacs,  it  is  carried  to  the  abdominal  brain. 
Then  the  irregular,  stormy  irritation  accumulated  in  the  abdominal  brain  is 
radiated  on  the  various  plexuses  of  nerves,  especially  in  the  direction  of  least 
resistance.  The  disturbance  of  rhythm  will  be  most  manifest  in  that  organ 
which  is  weakened  or  most  sensitive. 

We  will  consider  first  the  sudden  deaths  which  are  due  to  rupture  of 
blood-vessels  in  the  brain.  Such  sudden  deaths  are  apt  to  occur  in  elderly 
men  who  have  weak  arteries,  and  also  death  is  more  liable  to  occur  when  the 
man  is  cohabiting  with  a  strange  woman  for  the  first  time,  when  he  will  be 
the  most  excited.  Such  deaths  seldom  occur  with  men  who  repeatedly 
cohabit  with  the  same  woman,  when  excitement  is  but  ordinary.  The 
explanation  is,  that  the  irritation  goes  from  the  semen  sacs,  during  the  spasm 
of  expulsion,  to  the  abdominal  brain.  Here  the  irritation  is  reorganized  and 
radiated  to  the  vaso-motor  center.  The  irritation  may  also  go  up  the  spinal 
cord  to  this  center.  The  disturbance  in  the  vaso-motor  center  produces  nar- 
rowing of  the  caliber  of  the  peripheral  blood-vessels  and  thus  the  blood- 
pressure  is  suddenly  raised.     At  the  same  time  the  heart  is  slowed  and  hence 


234  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

the  force  is  increased.  It  pumps  the  blood  vigorously  into  the  arteries  and 
the  weak  wall  gives  way  under  the  sudden  pressure.  The  weak  cerebral 
artery  yields  to  the  excessive  blood-pressure,  and  death  follows  immediately 
from  blood  extravasation.  It  will  be  noted  that  all  such  deaths  have  occurred 
with  elderly  men  who  generally  have  weak,  atheromatous  arteries,  with 
degenerated  walls. 

In  cases  of  vomiting  and  fainting,  the  law  is  just  the  same.  The  irrita- 
tion due  to  the  emptying  of  the  semen  sacs  is  conveyed  to  the  abdominal 
brain  or  up  to  the  spinal  cord.  The  disturbed  energies  are  reflected  to  the 
heart  and  stomach,  and  fainting  and  vomiting  are  apt  to  arise.  It  comes 
under  the  same  law  as  vomiting  in  pregnancy.  In  domestic  animals,  faint- 
ing, vomiting  or  death  is  liable  to  occur  in  those  animals  which  have  a  short, 
intense  orgasm,  as  the  horse  or  pig.  The  orgasm  is  much  more  intense  in 
males,  and  hence  they  are  nearly  always  the  subjects  of  disturbances  during 
cohabitation.  Females  suffer  very  rarely.  All  this  profound  impression  in 
the  coition  of  animals  is  due  to  the  irritation  being  sent  to  the  abdominal 
brain,  where  it  is  reorganized  and  radiated  out  on  the  plexuses  of  the  various 
viscera.  The  sudden,  short  irritation  deranges  the  normal  rhythm,  and  hence 
the  pathology  of  fainting  and  vomiting.  The  disturbance  of  rhythm  will  be 
the  most  manifest  in  that  organ  most  sensitive  or  most  essential  to  normal 
life.     The  same  rules  apply  precisely  to  man. 

Men  during  coition  occasionally  faint,  vomit,  defecate,  urinate,  or  die. 
I  know  of  a  noted  judge  who  died  shoitly  after  connection  with  a  girl  in  a 
brothel.  In  Chicago,  a  short  time  ago,  at  one  of  the  principal  hotels,  a  man 
of  probably  forty-eight  was  found  dying  after  cohabiting  with  a  strange 
woman.  All  such  deaths  that  I  know  or  have  read  of  have  occurred  in 
elderly  men.  The  smaller  manifestations,  such  as  fainting,  vomiting,  uri- 
nation, and  defecation,  have  all  occurred  in  quite  young  men — mainly  at  the 
first  coition.  The  elderly  men  scarcely  ever  die  while  cohabiting  with  their 
wives,  as  they  are  familiar  with  them,  and  the  excitement  of  the  orgasm  is 
not  so  violent  or  intense.  It  generally  occurs  with  old  men  (in  age,  if  not  in 
years)  in  first  coition  with  a  strange  woman.  Death  may  occur  with  an  old 
man  who  has  not  had  connection  with  his  wife  for  a  long  period,  especially  if 
the  orgasm  is  intense.  I  do  not  include  in  such  a  subject  rupture  of  some 
pelvic  tumor,  due  to  coition.  The  explanation  of  the  matter  lies  in  the 
sympathetic  nerve  and  its  reflexes.  The  irritation  of  the  penis  is  due  to 
friction,  and  of  the  semen  sacs  to  spasm  and  evacuation,  which  is  transmitted 
to  the  abdominal  brain  and  there  reorganized. 

The  accumulated  irritation  in  the  abdominal  brain  is  radiated  rapidly  and 
on  the  various  directions  of  least  resistance.  It  rapidly  ascends  the  splanch- 
nics  and  is  reorganized  in  the  cervical  ganglia  and  sent  to  the  heart.  The 
irritation  sent  so  suddenly  to  the  heart  at  first  violently  stimulates  it  to  a 
vigorous  action,  so  that  the  blood-pressure  is  raised  to  a  high  tension  in 
the  brain,  especially  in  the  left  cerebral  artery.  Old  men  often  have  friable, 
degenerated  arteries,  and  this  sudden  rise  of  blood-pressure  induces  the 
middle  left  cerebral  artery  to  rupture,  and  thus  arises  the  death  from  coition. 


ANAL   NERVES  ABUNDANT  235 

The  primary  cause  is  the  reflexes  arising  from  the  semen  sacs  and  genitals. 
During  the  dissection  of  quite  a  number  of  cadavers,  I  have  noticed  that 
the  connections  of  the  lateral  chain  of  sympathetic  ganglia  are  very  large  at 
the  root  of  the  third  sacral  nerve.  It  must  be  remembered  that  the  third 
sacral  makes  up  nearly  all  of  the  pudic  nerve ;  also  that  all  the  external  geni- 
tals are  supplied  by  the  pudic  nerve. 

Hence,  we  find  that  the  pudic  nerve  connects  itself  with  one  of  the 
largest  ganglia  in  the  lateral  chain  of  the  pelvic  sympathetic.  Irritation  of  the 
external  genitals  is  quickly  carried  to  the  vaso-motor  center  by  the  close  and 
extensive  connection  of  the  cerebrospinal  sympathetic. 

The  rectum  and  anus  have  a  close  connection  with  the  sympathetic  nerve. 

The  anus  is  guarded  by  two  kinds  of  sphincters:  (a)  One,  the  internal 
sphincter,  ruled  by  the  sympathetic,  and  this  accounts  for  the  fact  that  rectal 
disease  (fissure,  ulcer)  creates  such  intense  disorder  and  neuroses  among  the 
viscera  through  violent  reflexes,  (b)  The  other  anal  sphincter,  the  external, 
is  dominated  by  the  spinal  nerves  and  does  not  create  such  wild  disorder 
among  the  viscera  by  reflexes. 

I  have  often  noticed  that  in  dilating  the  rectum  under  an  anesthetic,  the 
patient  would  utter  a  kind  of  hoarse  bray  or  expiratory  moan,  similar  to  the 
braying  of  an  ass  or  mule. 

The  reason  for  this  violent  braying  or  expiratory  moan  in  rectal  dilata- 
tion is,  that  there  is  a  distinct  nerve  strand  arising  from  the  inferior  cervical 
ganglion  and  passing  directly  to  the  phrenic,  which  controls  the  diaphragm, 
e.  g.,  rectal  dilatation  induces  the  irritation  to  pass  to  the  abdominal  brain 
over  the  hypogastric  plexus,  whence  it  is  reorganized  and  emitted  to  the 
inferior  cervical  ganglion  to  the  phrenic,  which  transmits  it  to  the  diaphragm, 
which  rapidly  forces  the  air  over  the  vocal  cords. 

The  mare  in  heat  will  often  utter  a  similar  sound.  If  the  mare  is 
watched,  she  will  be  seen  to  be  disturbed  occasionally,  every  five  to  eight 
minutes.  When  a  "spell"  or  disturbance  arrives,  she  will  first  raise  the  tail, 
and  then  begin  to  straddle  and  utter  a  kind  of  bray,  then  the  pudenda  is 
spasmodically  everted,  followed  by  the  emission  of  fluids  from  the  pudendo- 
vaginal  gland.  The  explanation  of  this  phenomenon  must  be  made  through 
the  pudic  and  sympathetic  nerves  of  the  rectum  and  genitals  on  the  one 
hand,  and  the  recurrent  laryngeal  and  sympathetic  on  the  other.  In  short, 
there  is  a  distinct  relation  between  the  voice  and  the  rectum.  This  connec- 
tion must  lie  in  the  sympathetic  nerve.  If  one  dilates  the  rectum  suddenly 
the  patient's  skin  capillaries  become  flushed  with  blood  and  sweating  is 
induced. 

One  of  the  most  prominent  features  of  patients  suffering  from  rectal  dis- 
ease is  their  manifest  nervousness.  Rectal  patients  become  irritable  and 
neurotic.  The  profoundly  rich  supply  of  the  hypogastric  to  the  rectum 
explains  why  disease  of  the  rectum  makes  neurotic  subjects. 

There  is  also  an  evident  connection  between  pelvic  disease  and  the  voice. 
Menstruating  women  are  likely  to  have  tonsillitis  congestion,  more  than 
non-menstruating   women.       Chronic   irritation   in   the    pelvic   organs  will 


236  THE  ABDOMIXAL  AXD   PELVIC  BRAIN 

induce  chronic  disease  in  the  tonsils  and  throat.  In  some  women  the 
voice  changes  at  menstruation  or  during  aggravation  of  pelvic  disease. 
Not  uncommonly  young  women  have  difficulty  in  swallowing  at  menstrual 
times,  and  their  hearing  may  be  a  little  disturbed,  because  of  the  congestion, 
and  the  chronic  inflammation  travels  up  the  Eustachian  tube.  The  distant 
relation  and  connection  between  the  ovary  and  parotid  gland  is  well  known, 
as  in  mumps  and  operations  on  the  ovary.  Few  writers  have  called  atten- 
tion to  the  relation  of  pelvic  disease  to  pharyngeal  disturbances,  which  exist 
by  means  of  the  connection  with  the  sympathetic.  The  relation  of  the 
tripod  in  exophthalmic  goiter — heart,  thyroid  gland  and  eyeball — will  be  more 
readily  understood  through  the  study  of  the  sympathetic  nerve.  The  enlarge- 
ment of  the  thyroid  in  the  menstrual  life  of  women  rests  on  the  sympathetic 
nerve.  The  sexual  life  of  woman  is  her  chief  life,  from  a  physical  stand- 
point, and  as  she  has  a  larger  ganglionic  system  than  man,  she  demands 
special  study ;  for  from  this  chief  function  of  her  life  will  arise  new  structures 
and  diseases. 

The  anus  is  the  last  to  become  insensible  under  chloroform.  One  can 
arouse  a  patient  who  is  supposed  to  be  dying  from  chloroform  anesthesia,  by 
suddenly  dilating  the  rectum;  the  peripheral  capillaries  will  also  dilate 
and  the  cardiac  and  respiratory  action  will  again  resume.  It  is  possible 
that  the  same  safety  arises  in  dilating  the  cervix  and  vagina  in  labor, 
as  then  we  may  give  chloroform  with  impunity.  The  heart  center  lies 
in  the  medulla,  and  one  often  observes  how  dilating  the  rectal  sphincter 
makes  the  capillaries  flush  and  the  skin  sweat.  Now,  the  very  opposite  often 
happens,  for  very  often  when  a  sphincter  is  dilated,  as  in  labor,  urinating  or 
rectal  dilation,  the  subject  has  a  distinct  chill.  This  is  due  to  the  disturbance 
carried  to  the  heat  center  in  the  medulla.  The  kind  of  irritation  which  pro- 
duces chill  and  the  kind  which  produces  heat  are  not  yet  determined,  but 
both  arise  by  means  of  the  sympathetic  nerve. 

Reflexes  from  the  rectum,  e.  g.,  fissure,  produce  just  the  same  distur- 
bance upon  the  system  as  do  reflexes  from  the  vagina  or  uterus.  Both  arise 
by  means  of  the  sympathetic,  and  both  result,  if  persistent,  in  malnutrition. 
The  reflexes  seem  to  alter  (stimulate,  depress  or  produce  irregularity)  the 
circulation  in  adjacent  or  remote  organs. 

It  is  well  known  that  young  girls  who  have  a  uterus  badly  developed  and 
anteflexed,  suffer  from  constipation  and  rectal  troubles.  It  is  likely  that  the 
constipation  and  rectal  trouble  is  mainly  due  to  reflex  action  by  means  of  the 
abdominal  brain.  It  is  known  that  long  continued  irritation  of  a  voluntary 
muscle  causes  fibrous  degeneration  and  finally  cicatricial  contraction.  Now  it 
is  also  well  known  that  women  possessed  of  rectal  trouble  soon  acquire 
uterine  trouble.  It  is  due  to  reflex  action,  the  rectal  irritation  is  sent  up  the 
abdominal  brain  and  reorganized  and  then  transmitted  to  the  uterus,  inducing 
circulatory  and  nutritive  disturbance. 

The  sympathetic  nerve,  as  its  name  implies,  is  liable  to  be  brought  in 
unison  with  surroundings.  For  example,  when  the  young  pregnant  wife 
begins  to  vomit,  the  young  husband  may  vomit  also,  a  purely  mental  impres- 


INFLUENCE   OF   GENITAL  NERVES  237 

sion  through  the  sympathetic  nerve.  The  effect  of  the  sympathetic  on  the 
glands  of  woman  is  important.  The  main  glands  are  (a)  mammary;  (b)  the 
sebaceous  on  the  face  and  (c)  those  of  the  pudendum.  As  soon  as  menstrua- 
tion begins  (or  a  little  later)  the  girl  begins  to  have  facial  acne.  The  sebace- 
ous glands  of  the  face  inflame,  enlarge  and  have  a  severe  exacerbation  at 
each  monthly.  Some  women  look  almost  as  if  they  were  chronic  drinkers  at 
the  time  of  menstruation.  A  monthly  rhythm  excites  and  exacerbates  the 
facial  sebaceous  glands  into  a  chronic  inflamed  condition.  (These  glands  may 
be  trying  to  imitate  the  glands  in  the  boy  in  enlarging  a  growing  beard.)  The 
trouble  is  due  to  the  sympathetic  and  is  especially  active  in  the  face  by 
reason  of  the  presence  of  the  ophthalmic  ganglia,  Meckel's  ganglia,  otic 
ganglia  and  sub-maxillary  ganglia — all  sympathetic  ganglia  situated  on  the 
fifth  cranial  nerve.  This  facial  acne,  highest  at  the  maximum  of  the  rhythm 
of  the  automatic  menstrual  ganglia,  is  very  annoying  to  many  women.  At 
the  climax  of  the  menstrual  rhythm,  there  may  be  noticed  on  some  women, 
dark  discolorations,  or  pigmentation,  just  below  the  eyes.  This  pigmentation 
of  the  eyelids  is  what  is  so  frequently  mentioned  as  the  dark  rings  about  the 
eyes.  It  is  due  to  deposit  of  pigment  induced  by  venous  congestion.  The 
congestion  is  brought  about  by  the  rhythmic  irritation  of  the  ophthalmic 
ganglia  (sympathetic)  on  the  supraorbital  branch  of  the  trigeminus.  The 
congestion  and  pigmentation  of  the  eyelids  in  menstruation  must  also  be 
connected  with  the  presence  of  large  glands  known  as  the  Meibomian  glands. 
The  sympathetic  nerve  has  a  predilection  and  a  dominating  influence  over 
glands;  so  that  the  eyelid  congestion  and  consequent  pigment  deposit  during 
menstruation  must  be  associated  with  the  ciliary  ganglia  of  the  Meibomian 
glands. 

In  the  pelvic  diseases  of  young  girls,  I  have  found  quite  frequently  an 
association  of  weak  eyes.  This  is  especially  the  case  with  endometritis, 
deficiently  developed  uterus  and  dysmenorrhea.  They  can  use  their  eyes  to 
read  but  a  few  minutes  at  a  time,  without  pain  or  the  letters  blurring.  I 
could  find  no  reference  to  the  subject  in  gynecological  text-books.  Since 
writing  the  above  I  have  learned  from  Dr.  B.  Bettman  that  Dr.  Fritsch  and 
others  have  investigated  the  connection  between  pelvic  and  eye  diseases.  It 
must  be  that  there  is  some  prominent  connection  between  certain  cases  of 
female  generative  disease  and  eye  trouble.  I  have  noted  so  many  cases  that 
I  cannot  consider  it  an  accident  and  believe  there  must  be  some  physiological 
connection.  The  eyes  are  worse  at  the  maximum  of  the  menstrual  rhythm. 
The  explanation  of  this  association  must  lie  in  the  sympathetic  nerve. 

I  suggested  the  subject  to  Dr.  Frances  Dickinson,  Professor  of  Ophthal- 
mology in  the  Chicago  Post-Graduate  School,  who  has  carefully  followed 
some  of  the  cases.  So  far,  the  doctor  has  reported  that  the  eye  trouble 
seems  to  be  in  the  general  circulation  of  the  eye,  the  visual  apparatus  (the 
cornea,  lens  and  retina)  being  normal.  The  endurance  of  the  eye  for  work 
is  lessened,  and  it  appears  to  me  that  the  chronic  defect  in  the  blood  canals 
is  accounted  for  by  the  disturbance  in  the  rhythm  of  the  diliary  ganglia,  and 
the  sympathetic  nerve   supply  of    the  Meibomian  glands    accounts  for    the 


238  THE  ABDOMINAL  AND  PELVIC  BRAIN 

pigmentation  of  the  lids.  What  role  the  lachrymal  glands  play  in  the 
matter   of  eye  trouble  through  the  sympathetic,  I  am  unprepared  to  state. 

The  associated  disturbances  of  the  mammary  glands  in  menstruation  and 
gestation,  have  attracted  the  attention  of  many  thinkers.  The  problem  must 
be  solved  through  the  sympathetic  nerve.  The  spinal  nerves  supplying  the 
mammary  glands  come  from  the  cervical  plexus  and  the  six  upper  dorsal 
nerves.  The  arteries  which  supply  the  gland  are  the  long  thoracic,  internal 
mammary,  the  intercostal  arteries  under  the  gland,  and  a  few  branches  from 
the  axillary  arteries.  Now,  on  these  arteries,  the  sympathetic  nerve  goes  to 
the  gland.  The  first  stage  of  milk  secretion  is  a  silent  process  reflected 
through  the  cord.  The  second  stage  is  a  gross  reflection  through  the  splanch- 
nic from  fetal  irritation  in  the  uterus;  the  cerebrospinal  nerves  elaborate 
milk,  but  the  sympathetic  hastens  its  secretion. 

The  original  irritation  nearly  always  arises  in  the  pelvic  organs.  It 
travels  to  the  mammary  gland  in  three  ways:  First,  by  the  way  of  the 
spinal  cord;  second,  by  way  of  the  lateral  chain  of  the  sympathetic;  third, 
the  main  way  is,through  the  hypogastric  plexus  to  the  abdominal  brain  and 
then  through  the  great  sensory  nerves  of  the  viscera,  viz. :  the  three  splanch- 
nics.  But  we  must  again  consider  that  the  mammary  gland  has  a  peripheral 
nerve  apparatus  which  not  only  shares  in  the  genital  rhythm,  but  also  has 
the  capacity  to  form  milk.  The  mammary  gland  must  be  looked  on  as 
simply  a  modified  sebaceous  gland  and  we  have  noticed  above  how  the  seba- 
ceous glands  of  the  face  are  affected  by  menstruation  and  gestation.  The 
spinal  nerves  do  not  induce  any  rhythm  in  the  glands  as  is  shown  in  girls  up 
to  puberty.  But  the  impetus  to  rhythm  must  suddenly  arise  at  the  peculiar 
condition  known  as  puberty,  or  the  period  of  tubal  motion. 

The  sebaceous  glands  on  the  pudendum  are  large  and  the  odor  at  men- 
struation is  chiefly  due  to  their  increased  secretion.  The  pudendal  glands 
are  remnants  of  ancient  life  when  the  female,  in  heat,  attracted  the  male  by 
the  increased  odor  emitted  from  the  active  glands.  The  odor  during  men- 
struation is  often  due  to  the  activity  cf  the  Pudendale  sebaceous  glands  and 
decomposition  of  their  products,  not  merely  to  decomposition  of  menstrual 
blood.  Here,  as  in  other  glandular  apparatus,  the  sympathetic  nerves  play 
an  important  part. 

The  sympathetic  nerve  seems  to  play  a  significant  role  on  the  heat 
centers  of  the  medulla.  I  have  noticed  this  especially  in  laparotomy  and 
vaginal  hysterectomy.  In  short,  when  certain  bundles  of  sympathetic  nerves 
are  cut,  especially  the  hypogastric  plexus,  the  temperature  will  rapidly  rise 
above  or  fall  below  normal. 

Surgeons  are  alarmed  at  these  manifestations  until  experience  teaches 
their  real  meaning. 

The  practical  application  of  the  sympathetic  nerve  in  gynecological  work 
lies  in  its  control  over  nutrition.  Reflex  irritation  from  a  pelvic  viscus  will 
remotely,  or  through  several  years,  impair  the  whole  visceral  economy. 
Remote  effects  of  pelvic  disease  must  be  traced  through  the  nervous  system 
(sympathetic)  due  to  circulatory  modifications. 


AUTOMATIC    VISCERAL    GANGLIA  239 

The  connection  of  the  cerebral  cortex  (the  seat  of  epilepsy),  with  ovarian 
diseases,  resulting  in  so-called  hystero-epilepsy,  is  far  from  being  proven. 

The  different  sizes  of  the  peripheral  ganglia  in  the  various  viscera  is  an 
important  element  in  studying  the  sympathetic.  Some  viscus  may  have 
abnormally  small  ganglia  and  hence  its  rhythm  and  nutrition  will  be  defec- 
tive. Small  automatic  cardiac  or  menstrual  or  gastro-intestinal  peripheral 
ganglia  will  be  unable  to  do  normal,  vigorous,  nutritive  and  rhythmic  work, 
thus  making  the  visceral  system  defective. 

Menstruation  and  the  menopause  I  shall  place  in  the  realm  of  the  sym- 
pathetic nerve.     The  peculiar    cycles  and  rhythms    throughout  the    life  ofi 
woman  demands  attention.     We  may  call  attention  to  the  wide  domain  of  the  ' 
sympathetic  nerve  not  only  in  health,  but  also  in  disease.      Having  made 
considerable  investigation  in  this  subject,  some  of  the  resulting  views  may  be 
of  interest  and  may  stimulate  the  study  of  the  sympathetic  nerve. 


CHAPTER  XX. 

THE  AUTOMATIC  MENSTRUAL  GANGLIA. 

The  function  of  the  tractus  genitalis  is:     Sensation,  ovulation,  secretion,  absorp- 
tion, peristalsis,  menstruation,  gestation. 

'We  are  shaped  and  fashioned  by  what  we  love." — Goethe. 

Menstruation  is  a  regular  periodic  monthly  rhythm  of  the  uterus  and  ovi- 
ducts. In  general  it  begins  at  the  age  of  15  and  ceases  at  45,  continues  foui 
days,  the  bloody  flow  amounting  to  two  ounces  and  should  be  painless. 

Menstruation  belongs  distinctly  to  the  oviducts  and  uterus.  It  is  a  sing- 
ular rhythmic  action.  It  is  controlled  by  the  automatic  menstrual  ganglia 
situated  in  the  walls  of  the  oviducts  and  uterus.  These  rhythmic  little  brains 
manifest  themselves  to  the  observer  by  circulatory  change  and  increased 
motion.  Menstruation  might  be  named  oviductal  motion.  By  direct  obser- 
vation in  the  human,  and  also  in  animals,  I  have  noted  the  following  con- 
dition midway  between  the  monthly  periods,  or  at  times  far  remote  from  oes- 
trus or  rutting:  The  oviducts  and  uterus  are  of  quite  a  pale  pink  color.  In 
short,  they  are  not  congested,  and  are  in  repose.  But  at  the  menstrual  peri- 
od or  season  of  oestrus  the  oviducts  and  uterus  are  congested  and  in  active 
peristaltic  motion.  The  oviducts  are  of  a  dark  blue  color  from  their  dilated 
vessels  being  filled  with  blood.  The  congestion  of  the  uterus  is  intense  but 
not  so  manifest  as  the  oviducts.  The  oviducts  are  swollen,  thickened  and 
oedematous.     They  are  soft  and  pliable. 

At  this  time  a  slight  irritation  while  removing  them  soon  excites  them 
into  active  peristaltic  motion.  After  removing  such  oviducts  and  placing 
them  in  warm  (salt)  water  they  will  maintain  vermicular  movements  for 
half  an  hour  by  gentle  irritation.  I  have  been  able  to  make  these  observa- 
tions in  women  because  I  operate  at  any  time  in  laparotomy,  after  careful 
preparation,  even  if  it  be  in  the  midst  of  a  menstrual  period.  As  regards 
animals  I  have  examined  several  hundred  genitals  of  recently  butchered 
sows,  and  the  oviductal  congestion  at  the  oestrus  is  more  apparent  in  them 
than  in  the  woman.  The  sow's  uterus  is  also  probably  more  congested. 
Observations  and  experiments  indicate  that  menstruation  is  a  regular, 
periodical  rhythm  of  a  blood-wave  in  the  oviducts  and  uterus  induced  by  the 
automatic  menstrual  ganglia.  The  continually  moving  wave  rises  to  a  maxi- 
mum and  sinks  to  a  minimum.  The  menstrual  wave  continues  from  puberty 
to  the  menopause.     It  is  a  nervous  phenomenon. 

Ovulation  is  a  progressive,  non-periodical  process.  It  begins  before  birth 
and  continues  until  the  ovarian  tissue  is  atrophied  or  worn  out.  It  is  liable 
to  occur  at  menstruation  or  cestus  because  of  the  vast  blood-supply  at  that 
time  which  hastens  the  follicle  to  ripen  and  burst.  In  the  lower  animals,  so 
far  as  I  can  decide,  menstruation  and  ovulation  seem  to  be  coincident,  i.  e., 

240 


AUTOMATIC  VISCERAL  GANGLIA  241 

they  occur  at  the  same  time.  I  have  examined  the  cow,  dog  and  sheep,  but 
my  observation  is  especially  based  on  the  ovular  and  menstrual  process  as 
seen  in  the  sow.  By  the  examination  of  some  two  hundred  and  fifty  speci- 
mens of  sow's  genitals  in  all  conditions  it  seems  to  me  that  the  oestrus  of  the 
animal  embraces  both  menstruation  and  ovulation  in  one  physiologic  process 
at  the  same  time.  But  as  the  scale  of  animal  life  ascends,  the  processes  of 
menstruation  and  ovulation  seem  to  become  more  and  more  divorced.  To 
my  mind,  the  best  animal  to  begin  with  is  the  ofow.  In  the  cow  one  can  see 
more  and  more  distinct  processes  with  the  ovaries  and  oviducts.  Their 
separate  workings  become  more  apparent.  In  the  calf,  before  and  after 
birth,  ovulation  is  very  manifest.  But  the  oviducts  and  uterus  before 
birth  and  for  a  considerable  time  after,  are  manifestly  quiet  and  pale  and 
rudimentary,  non-functional.  In  woman  it  is  my  observation  that  menstrua- 
tion and  ovulation  are  found  distinctly  separate  from  each  other.  It  is  true 
that  ovulation  and  menstruation  may  occur  together,  may  be  coincident,  but 
that  is  an  accident.  The  processes  are  physiologically  separate.  In  the 
woman  ovulation  has  been  observed  before  birth,  and  I  have  seen  ovulation 
in  a  woman  of  70,  the  specimens  of  which  were  presented  to  me  by  Dr.  Bur- 
gess of  Milwaukee.  Now,  of  these  two  great  physiologic  functions,  ovulation 
is  a  life-long  process.  It  begins  before  birth  and  ends  with  ovarian  atrophy. 
But  menstruation  is  a  periodical  process  beginning  with  puberty  and  ending 
with  the  menopause.  Puberty  must  be  observed  as  initiating  the  new  exer- 
cise of  genital  ganglia.  A  viscus  assumes  a  new  rhythm  which  disturbs  the 
entire  system. 

The  views  here  contained  are  that  menstruation  is  governed  by  nervous 
ganglia  situated  in  the  walls  of  the  oviducts  and  uterus.  I  have  designated 
these  nervous  structures  as  automatic  menstrual  ganglia.  As  a  deduction 
of  this  theory,  oviductal  motion  and  oviductal  changes  will  be  considered  the 
most  marked  phenomena  of  menstruation.  The  question  may  be  asked : 
What  is  a  nervous  ganglion?  A  nervous  ganglion  is  a  collection  of  nerve 
cells.  Its  constituents  are  nerve  cells  and  nerve  fibers.  It  is  an  ideal  nervous 
center  having  a  central,  conducting  and  peripheral  apparatus.  A  ganglion 
is  a  little  brain,  a  physiological  center.  It  has  the  power  of  receiving  sensa- 
tion and  transmitting  motion.  It  is  automatic  in  itself.  It  possesses  the 
power  of  nourishment  and  controls  secretion.  Reflex  action  can  be  demon- 
strated in  it.  What  are  called  motor,  sensory,  and  sympathetic  nerve  fibers 
are  found  in  its  composition.  The  peculiar  feature  of  a  nervous  ganglion  is 
rhythm.  It  performs  cyclical  movements.  It  has  a  periodic  function  which 
continually  waxes  to  a  maximum  or  wanes  to  a  minimum.  It  lives  a 
rhythmic  life.  Its  periods  of  action  vary  from  a  few  seconds  to  a  month.  It 
is  beyond  the  control  of  the  will. 

1.  The  proof  of  the  existence  of  the  ganglia  in  the  oviducts  and  uterus 
is  from  analogy.  All  hollow  viscera  have  ganglia  in  their  walls.  Histologists 
have  long  known  that  many  viscera  possess  ganglia  which  have  automatic 
power.  The  names  of  Bidder,  Schmidt,  Ludwig,  Remak  Meissner  and  Auer- 
bach  are  associated  with  the  discovery  and  description  of  these  viscera 
ganglia. 

16 


242  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

(a)  I  have  satisfied  myself  many  a  time,  in  vivisection  on  dogs  and  other 
animals,  that  the  heart  has  nervous  centers  or  ganglia,  which  will  continue 
to  act  independently  of  their  cerebrospinal  connection.  It  is  not  only  clear 
that  the  heart  has  automatic  ganglia,  but  that  nearly  all  these  ganglia  are 
centered  in  the  walls  of  the  auricles.  I  have  often  watched  the  heart's 
action  gradually  die  out  from  apex  to  base.  We  know  by  experiment  that 
the  heart  will  perform  its  cycle  of  contraction  independently  of  its  external 
connection.  These  automatic  nervous  ganglia  situated  in  the  wall  of  the 
heart  keep  up  its  rhythm,  its  cyclical  action,  its  periodic  movements.  They 
explode  oftener  than  once  a  second.  I  have  severed  the  heart  from  its 
attachments  in  some  animals  and  watched  its  beating  cease,  when,  if  left 
alone,  it  would  be  still  forever;  but  by  applying  stimulus  to  the  ganglia  the 
heart  would  again  perform  its  rhythm.  It  would  beat  and  explode  just  the 
same  as  when  it  was  connected  to  the  cerebrospinal  system.  Hence  few 
observers  doubt  that  the  ganglia  of  Remak,  Bidder,  Ludwig  and  Schmidt  sus- 
tain and  control  the  rhythm  of  the  heart.  One  can  prove  by  experiment  that 
there  are  several  ganglia  situated  in  the  auricle  by  cutting  pieces  out  of  its 
wall.     If  these  pieces  are  stimulated  they  will  go  through  a  distinct  rhythm. 

(b)  A  large  number  of  experiments  on  the  intestines  of  animals  (especi- 
ally the  dog)  convinced  me  distinctly  that  the  intestines  are  endowed  with 
automatic  ganglia  in  a  similar  manner  to  the  heart.  These  ganglia  are  called 
the  plexus  of  Auerbach  and  the  plexus  of  Meissner-Billroth.  If  a  dog  is 
killed  and  the  abdomen  is  opened  in  a  room  of  75°  F.,  the  intestines  can  be 
induced  to  perform  peristalsis  for  an  hour  after  death  by  tapping  them  occa- 
sionally with  a  scalpel.  As  soon  as  the  intestines  are  exposed  to  the  air  or 
tapped  with  the  scalpel,  they  begin  to  go  through  wonderful  vermicular 
movements  resembling  a  moving  bundle  of  angle-worms.  I  have  often 
demonstrated  the  peristaltic  movement  of  the  intestines  more  than  an  hour 
after  death,  so  that  it  can  be  stated  that  the  automatic  ganglia  of  the  bowels 
will  perform  their  rhythm  independently  of  the  cerebrospinal  center.  In 
autopsies  I  have  found  the  intestines  invaginated,  and  from  the  non-congested 
and  non-inflammatory  condition  of  the  intestinal  wall  I  had  no  doubt  the 
invagination  occurred  entirely  after  the  patient's  death.  The  non-inflamma- 
tory telescoping  of  the  intestines  in  dying  subjects  is  called  the  "invagination 
of  death."  It  can  be  perfectly  demonstrated  in  a  dog's  intestines  fifteen  to 
thirty  minutes  after  he  is  dead.  Hence  the  nervous  bulbs  studded  over  the 
plexus  of  Auerbach  and  the  plexus  of  Meissner-Billroth  are  the  automatic 
ganglia  which  induce,  sustain,  and  control  the  rhythm  of  the  intestines. 
The  vigorous  rhythmic  exercise  or  explosion  of  the  intestinal  ganglia  is 
what  causes  colic,  and  in  bowel  constriction  occurring  in  patients  having 
thin  belly  walls  I  have  observed  this  with  perfection.  The  intestinal 
rhythm  caused  by  the  ganglia  can  be  beautifully  seen  in  the  defecating 
intestine  of  a  patient  on  whom  colotomy  has  been  performed. 

I  have  never  seen  the  causation  of  the  very  severe  pain  in  angina  pectoris 
very  satisfactorily  explained.  I  would  suggest  that  it  is  colic  of  the  heart, 
caused  by  abnormally  vigorous  action  of  the  heart's  automatic  ganglia;  that 


AUTOMATIC  INTESTINAL  GANGLIA 


243 


the  desperate  pain  in  angina  pectoris  is  due  to  the  excessive  exercise  or 
abnormally  vigorous,  irregular  rhythm  of  the  automatic  ganglia  situated  at 
the  base  of  the  heart.  Hence,  clinically,  no  doubt,  we  see  the  abnormally 
vigorous  rhythm  or  irregular  rhythm  of  the  heart  in  what  is  called  neuralgia 
or  spasm  of  the  heart,  or  angina  pectoris.     The  ganglia  offer  the  best  expla- 


FIG.58—  PELVIC    BRAIN    OF    ADULT. 

PELVIC  BRAIN 

Fig.  58.     This    illustration   presents  a  fragment   of   the   luxuriant  nerve  supply  of  the 
uterus,  oviducts  and  ovaries. 


nation.       Clinically,  we  see  in  the  intestines  the  exercise  of  Auerbach's  and 
Meissner's  ganglia  in  various  diseases. 

In  colic  and  also  bowel  obstruction  we  see  an  excessively  vigorous, 
irregular  action  of  the  ganglia.  We  note  an  excessively  irregular  action  of 
the  ganglia  in  the  desperate,  painful  colic  of  children,  which  I  believe 
amounts  in  many  cases  to  an  invagination  with  subsequent  spontaneous  dis- 
invagination.  It  may  be  noted  that  irregular  action  of  the  bowel  ganglia 
occurs  in  children  where  the  cerebrum  is  insufficiently  developed  to  force  the 


244  THE  ABD0M1XAL  AXD  PELVIC  BRAIX 

ganglia  of  Meissner  and  Auerbach  into  subjection  and  thus  secure  a  regular 
rhythm  of  the  intestine.  We  also  see  irregular  ganglionic  action  in  the 
bowel  where  the  cerebrum  is  diseased  and  hence  has  lost  a  controlling 
influence.  In  chronic  constipation,  and  in  the  paralysis  of  the  intestine  dur- 
ing peritonitis,  we  see  disease  of  the  ganglia  producing  such  loss  of  power 
that  the  ganglia  cannot  initiate  or  sustain  sufficient  peristalsis  to  expel  the 
bowel  contents. 

(c)  The  same  statement  can  be  made  relative  to  the  bladder.  It  is  sup- 
plied with  two  kinds  of  nerves.  One  kind  is  the  cerebrospinal.  The  other 
kind  is  the  sympathetic  nerves,  which  especially  go  to  the  body  and  summit 
of  the  bladder.  These  nerves  are  studded  over  with  ganglia  which  may  be 
styled  automatic  vesicular  ganglia.  These  ganglia  are  closely  associated 
with  the  blood-vessels  and  walls  of  the  bladder,  and  have  an  influence  in  con- 
trolling the  rhythm  of  this  cyst.  As  an  example  to  demonstrate  the  action 
of  the  automatic  ganglia  in  the  bladder,  I  took  from  a  stag  weighing  fourteen 
hundred  pounds,  the  bladder,  penis  and  rectum.  Twelve  hours  after  it  was 
contracted  quite  small.  I  then  dilated  it,  and  thirty-six  hours  after  it  had 
again  contracted  smaller  than  ever  and  would  not  contain  half  a  pint  of  fluid. 
This  bladder  continued  its  rhythmic  action  for  mere  than  forty  hours.  It  is 
not  mere  elasticity,  as  one  can  watch  the  rhythm  of  segments.  It  can  be 
well  demonstrated  by  injecting  its  blood-vessels  with  red  fluid  and  then 
watching  it  for  a  day,  when  the  slow,  cyclical  rhythm  can  be  plainly  seen. 
The  sacral  spinal  nerves  preponderate  at  the  neck  of  the  bladder  and  endow 
it  with  sensation.  They  likely  hinder  it  from  rhythm,  while  the  body  and 
summit  of  the  bladder  are  mainly  supplied  with  sympathetic  nerves.  They 
give  it  blunt  sensation  and  rhythm.  But  the  summit  and  body  of  the  bladder 
are  the  parts  endowed  with  ganglia,  and  they  are  also  the  parts  endowed 
with  cyclical  rhythm. 

If  a  rubber  bag  is  inserted  into  the  bladder  and  then  filled  with  fluid, 
having  its  external  end  connected  with  a  mercury  gauge,  it  can  be  plainly 
seen  that  the  bladder  undergoes  intermittent  contraction.  It  will  demon- 
strate its  rhythm.  Clinically,  this  rhythm  can  often  be  observed  in  retention 
of  urine.  The  filling  bladder  will  periodically  make  vigorous  efforts  to  expel 
i:s  contents,  and  the  pain  felt  at  those  times  can  be  easily  mistaken  for  colic. 
Hence  the  bladder  is  endowed  with  automatic  vesical  ganglia,  which  are 
mainly  situated  in  the  walls  of  the  body  and  summit,  especially  localized  along 
its  highways  of  nutrition  (blood  and  lymph  tracts).  These  ganglia  preside 
over  the  rhythm  of  the  bladder. 

(d)  The  analogies  of  the  heart,  intestines  and  bladder  are  quite  appar- 
ent, and  can  reasonably  be  carried  to  the  uterus  and  oviducts.  They  are  all 
hollow  organs.  The  oviducts  and  uterus  are  no  exception  to  the  other 
abdominal  viscera.  What  is  said  in  this  paragraph  is  the  result  of  examina- 
tion of  over  seven  hundred  uteri,  oviducts  and  ovaries,  of  woman,  cow,  pig, 
sheep  and  dog.  Some  of  the  examination  was  carried  on  during  the  life  of 
the  animal,  and  in  quite  a  number  of  cases  I  noticed  the  action  of  the 
oviducts  in  the  living  woman  during  operation.     Much    of  the  work  was  done 


AUTOMATIC  VESICAL  AND  CARDIAC  GANGLIA  245 

on  freshly  butchered  animals,  where  the  organs  were  removed  before  the 
general  muscular  twitching  had  ceased.  My  first  distinct  attention  was  drawn 
to  the  idea  that  the  heart,  intestines,  uterus  and  oviducts  acted  similarly,  by 
observation  in  the  slaughter  house.  Dr.  C.  S.  Miller  and  myself  were  watch- 
ing the  slaughter  and  evisceration  of  a  cow  weighing  fifteen  hundred  pounds. 
The  cow  was  in  the  eighth  month  of  pregnancy.  The  butcher  amputated  the 
large  uterus,  containing  the  calf,  a  little  above  the  internal  os.  I  noticed 
that  the  amputated  portion  of  the  uterus  containing  the  calf  went  through  a 
peculiar  series  of  rhythmic  motions.  But  the  interesting  scene  was  the 
amputated  stump  left  on  the  body  of  the  cow.  The  stump  was  about  six 
inches  long  and  three  inches  thick.  This  stump  performed  its  peculiar 
rhythm  long  after  the  cow  was  dead.  It  slowly  described  circles  and  arcs 
with  diameters  varying  from  an  inch  to  four  inches.  Each  muscular  layer 
of  that  thick  uterus  worked  in  perfect  harmony.  No  uterine  layer  of  muscles 
interfered  with  any  other.  Every  part  of  the  uterine  stump  seemed  to  work 
with  intelligence  or  a  kind  of  quasi-judgment  during  the  rhythm.  At  one 
time  the  circular  muscular  layer  would  go  through  a  slow  but  distinct 
rhythmic  circle  before  any  other  muscular  layer  would  begin.  Then,  grad- 
ually, the  longitudinal  muscular  layer  would  begin  to  act,  and  the  end  of  the 
stump  would  describe  a  rhythmic  cycle,  and  thus  it  continued  to  repeat  the 
rhythmic  action  until  we  left,  an  hour  after.  During  the  activity  of  the  stump 
the  most  striking  example  of  the  action  of  the  two  muscular  layers  of  the 
uterus  could  be  seen,  for  while  one  layer  worked  vigorously  the  other 
remained  still.  Another  striking  example  to  show  that  the  hollow  uterus  has 
its  own  automatic  ganglia  may  be  observed  by  removing  the  uterus  from  a 
cow  immediately  after  death.  The  uterus  should  be  that  of  a  multiparous 
cow,  because  such  have  long,  thick,  tortuous,  helicoid  arteries.  Now  care- 
fully inject  the  utero-ovarian  arteries  with  red  fluid.  Observation  will  easily 
detect  rhythm  in  the  segments  of  this  uterus  for  some  forty  hours  after 
death,  in  a  75°  room.  The  rhythmic  waves  that  pass  over  the  uterus  will 
shift  the  fluid  from  one  segment  to  another,  so  that  the  quantity  of  fluid  is 
not  uniform  in  each  segment.  The  rhythm  sometimes  takes  place  very 
slowly.  This  phenomenon  is  not  elasticity.  But,  clinically,  the  rhythm  of 
the  pregnant  uterus  has  been  known  since  the  art  of  obstetrics  began.  My 
purpose  here  is  simply  to  draw  attention  to  the  independent  action  of  the 
uterus  from  a  cerebrospinal  connection,  and  to  show  that  the  uterus  has 
automatic  ganglia  like  other  hollow  viscera. 

Labor  will  take  place  under  profound  anesthesia.  Children  have  been 
expelled  from  the  uteri  of  dead  women.  All  this  is  due  to  the  nerve  appara- 
tus of  the  uterus.  Some  Frenchman  severed  the  spinal  cord  of  a  pregnant 
sow  below  the  brain,  thus  paralyzing  all  the  voluntary  muscles  which  aid  in 
parturition,  yet  the  sow  had  her  pigs.  The  uterus  drove  one  fetus  into  the 
vagina,  but  as  the  abdominal  muscles  were  paralyzed  this  fetus  had  to  be 
driven  out  by  the  second  fetus,  which  was  pushed  against  the  first  by  the 
contracting  uterus. 

(c)     The  oviduct  is  simply  a  continuation  of  the  muscular  walls  of  the 


216  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

uterus,  but  not  of  the  endometrium.  The  endometrium  seems  to  be  a  tem- 
porary gland,  whose  duration  of  active  life  is  the  menstrual  period.  The  an- 
alogy of  the  hollow  oviduct  of  the  intestine  or  heart  is  very  close.  Nearly  all 
the  original  work  done  on  this  subject  was  in  relation  to  the  oviducts,  for  I 
consider  them  the  most  important  organ  in  menstruation.  The  object  of 
menstruation  is  to  transport  an  egg  from  the  ovary  to  the  interior  of  the 
uterus.  This  can  be  done  by  a  properly  prepared  oviduct.  It  seems  to  me 
that  menstruation  begins  and  ends  in  the  oviducts,  and  that  the  importance 
of  the  oviducts  overshadows  all  other  organs  in  menstruation,  however,  the 
endometrium  is  the  important  prepared  nest.  When  the  oviducts  begin  their 
rhythm  the  girl  has  arrived  at  puberty.  Oviductal  motion  is  a  sign  of  woman- 
hood. When  the  oviducts  begin  their  cycles  it  is  a  heraldic  sign  that  the  gland 
called  the  endometrium  is  prepared  to  nourish  an  ovum.  The  endometric 
gland  is  no  doubt  often  prepared  to  nourish  an  ovum  before  the  oviductal 
motion  or  menstruation,  and  from  the  examination  of  nearly  eight  hundred 
ovaries  I  am  fully  satisfied  that  ovulation  goes  on  from  before  birth  until  the 
end  of  life,  or  till  the  germinal  epithelium  is  worn  out.  Actual  observation 
of  animals  convinced  me  of  this.  One  can  see  no  changes  in  the  ovary  at 
puberty,  except  that  of  increased  vascular  supply.  I  never  could  find  any 
periodicity,  nor  signs  of  it,  in  the  ovulation  in  the  human,  cow  or  sheep. 
The  ovules  simply  ripen  progressively  and  burst  when  they  are  mature, 
whether  that  be  at  menstruation  or  at  some  other  time.  I  am  sure  they  often 
burst  by  mere  mechanical  accident.  Hence,  it  does  seem  that  menstruation 
and  ovulation  are  two  different  processes.  Two  statements  may  then  be 
made  relative  to  an  egg  being  carried  into  the  uterus:  First,  when  the 
oviduct  goes  through  its  menstrual  rhythm  it  may  secure  an  agg,  if  it  hap- 
pens to  be  ready  and  bursts.  Second,  the  oviduct  may  secure  an  egg,  if  its 
fimbriated  funnel  becomes  glued  on  to  the  ovary  at  a  point  where  there  is  a 
maturing  ovum. 

2.  The  Proof  of  the  Existence  of  the  Ganglia  in  the  Oviducts  from 
Direct  Obsa-vation  and  Experiment. — If  an  adult  female  dog  is  taken  and 
well  anesthetized,  and  the  abdomen  opened,  the  short  white  oviducts  can  be 
found  just  posterior  to  the  kidney,  at  the  abdominal  end  of  the  double  uterus. 
Two  important  matters  will  be  observed — first,  the  condition  of  the  oviduct; 
second,  the  position  of  the  oviduct.  If  the  animal  is  not  in  rut,  which  is  very 
analogous  to  menstruation,  the  oviducts  will  be  very  white,  small  and  still. 
They  are  very  much  contracted,  and  the  fimbriated  end  generally  lies  as  far 
from  the  ovary  as  the  fimbria  ovanca  will  permit.  In  short,  in  the  inter- 
cestrual  time  non-congestion  and  quiescence  mark  the  oviductal  condition. 
The  condition  and  position  of  the  oviduct  at  the  period  of  rut  are  wonder- 
fully changed.  The  oviduct  is  very  much  swollen  and  elongated;  it  is  dark 
blue  from,  especially,  venous  congestion.  The  surrounding  blood-vessels 
are  enlarged,  tortuous  and  distended.  The  oviduct  shows  convolutions  and 
tortuosities  plainer  now  than  at  other  times.  The  oviduct  having  become 
longer  and  thicker,  its  entire  position  is  changed.  The  strip  of  (muscular) 
tissue  which  connects  the  fimbriated  end  of    the  oviduct  to  the  ovary  has 


AUTOMATIC  MENSTRUAL  GANGLIA  247 

shortened,  and  the  funnel  mouth  of  the  oviduct  is  closing  on  to  some  portion 
of  the  ovary.  At  the  climax  of  the  menstrual  rhythm  the  fimbriated  mouth 
of  the  oviduct  is  often  glued  or  cemented  on  to  the  ovary  by  a  kind  of  glairy 
mucous  exudate.  The  careful  examination  of  nearly  eight  hundred  oviducts 
satisfactorily  demonstrated  to  me  that  the  oviducts  go  through  a  distinct 
rhythm  at  menstruation.  Menstruation  is  a  periodic  cycle  of  the  oviducts. 
The  oviducts  go  through  a  peristaltic  or  vermicular  motion  exactly  analogous 
to  the  intestine.  Now,  there  is  only  one  kind  of  apparatus  which  produces 
a  rhythm,  and  that  is  a  ganglion.  Hence,  as  the  oviducts  go  through  a 
rhythm,  they  must  be  influenced  by  a  ganglion. 

The  changes  in  the  oviduct  at  puberty  are  as  follows:  (a)  It  assumes 
rhythmic  movements;  (b)  its  muscular  action  increases;  (c)  its  vascularity 
is  much  increased;  (d)  it  becomes  extended  and  loses  its  corkscrew  or  spiral 
shape  of  fetal  life;  (e)  its  epithelium  becomes  ciliated;  (f)  its  gross  activity 
appears  mainly  at  the  abdominal  end;  (g)  its  lumen  becomes  filled  with  fluid. 
This  fluid  is  to  float  the  egg  or  ovum  into  the  uterus.  The  cilia  whip 
the  fluid  in  the  oviduct  into  a  current,  and  this  wonderful  anatomic  and 
physiological  canal  floats  the  ovum  to  the  nourishing  gland — the  endometrium. 
The  automatic  menstrual  ganglia  during  their  rhythm  produce  such  changes 
in  the  oviduct  as  will  best  prepare  it  to  float  an  egg  from  the  ovary  to  the 
uterus.  As  the  rhythmic  peristalsis  of  the  oviduct  reaches  its  climax  the 
oviduct  becomes  thicker,  longer  and  its  caliber  wider.  The  fimbria  ovarica 
shorten  and  draw  an  oviductal  funnel  over  a  part  of  the  ovary.  A  dry, 
contracted  oviduct  with  a  narrow  lumen  offers  difficulties  for  the  passage  of 
an  ovum.  If  the  epithelium  of  the  oviduct  is  so  altered  by  disease  that  it 
does  not  secrete  fluid,  the  egg  may  not  be  able  to  float  through  the  oviductal 
canal,  but  may  become  arrested  in  its  passage,  causing  ectopic  pregnancy. 
The  reason  why  an  egg  does  not  get  into  a  child's  uterus  is  because  its 
oviduct  is  deficient  in  motion;  the  fluid  in  its  interior  and  the  ciliated 
epithelium  are  deficient.  The  ciliated  epithelium  whips  an  egg  into  the 
uterus  by  means  of  a  fluid  medium.  The  rhythm  of  the  oviducts,  caused  by 
the  ganglia,  prepares  them  for  their  function.  This  is  done  by  first  drawing 
the  mouth  of  the  oviduct  over  a  part  of  the  ovary;  and,  second,  by  flooding 
the  lumen  of  the  oviduct  with  serous  fluid.  Of  course  it  will  be  only  acci- 
dental that  the  mouth  of  the  oviduct  will  cover  a  matured  ovum.  The  vast 
majority  ovulate  into  the  peritoneal  cavity.  Ovulation  is  a  life-long  process, 
while  menstruation,  or  rather  oviductal  rhythm,  lasts  about  thirty  years. 

The  almost  entire  separation  of  the  oviduct  from  the  ovary  is  peculiar 
to  the  higher  animals,  and  no  doubt  lessens  the  chances  of  excessive  repro- 
duction. In  the  hen  the  ovary  and  oviduct  are  continuous.  The  active 
explosion  of  the  automatic  menstrual  ganglia  are  the  most  marked  at  the 
abdominal  end  of  the  oviduct.  By  direct  experiment  it  is  easy  to  make  the 
oviducts  perform  their  rhythmic,  vermicular  movements  for  half  an  hour 
after  their  removal  from  the  living.  The  oviducts  of  a  cow,  sheep,  dog  or 
pig  can  be  kept  moving  in  a  warm  medium  by  stimulating  or  pinching  them, 
just  in  the  same  manner  as  pinching  the  heart  or  tapping  the  intestines  will 


248  THE  ABDOMINAL  AND  PELVIC  BRAIN 

keep  up  the  movements  of  those  organs  in  vivisection.  I  have  made  this 
experiment  many  times  on  the  normal  oviducts  of  women  where  they  were 
removed  for  various  causes.  While  the  operation  is  progressing  one  can  see 
the  oviducts  going  through  a  rhythm  from  mere  manipulation.  As  soon  as  an 
oviduct  is  removed,  if  it  be  normal,  a  rhythmic  action  may  be  produced  by 
pinching  it.  The  two  muscular  layers  of  the  oviduct  will  work  separately 
before  the  eye.  The  external  longitudinal  muscular  layer  shortens  the  ovi- 
duct, while  the  internal  circular  muscular  layer  narrows  the  oviductal  lumen. 
An  oviduct  will  maintain  this  rhythmic  motion  for  about  half  an  hour,  if 
pinched  or  stimulated  in  a  medium  (salt  water  is  a  very  good  medium). 

The  large  range  of  movement  of  a  human  oviduct  under  stimulation  is 
very  marked,  and  the  vigorous  manner  in  which  the  two  muscular  layers  of 
the  oviduct  work  is  very  noticeable.  If  the  circular  layer  is  well  stimulated, 
it  will  contract  with  such  vigor  as  to  resemble  a  pale,  contracted  band  around 
the  point  of  irritation.  The  endometrium  may  be  looked  on  as  a  temporary 
gland,  whose  duration  of  life  is  the  child-bearing  period.  So  the  automatic 
menstrual  ganglia  which  govern  the  rhythm  of  the  oviducts  and  uterus,  and 
make  fecundation  possible  are  only  temporary  ganglia,  at  least  so  far  as 
function  goes.  The  automatic  menstrual  ganglia  begin  their  functional  life 
in  the  incipient  oviductal  motion. 

This  is  not  the  only  organ  that  acts  merely  at  a  definite  period  of  life, 
though  the  organs  exist  anatomically  during  the  whole  of  life.  The  thymus 
gland  is  largest  at  birth.  The  thyroid  gland  becomes  most  active  in  girls  at 
about  fifteen.  The  sebaceous  glands  of  males  spring  into  functional  activity 
at  about  eighteen.  When  the  menstrual  ganglia  of  woman  begin  to  cease 
their  functions  forever,  the  sebaceous  glands  of  the  face  assume  an  active 
function,  and  a  beard  results.  The  salivary  glands  do  not  act  for  three 
months  after  birth.  No  doubt  the  facial  sebaceous  glands  existed  always, 
anatomically  but  not  functionally.  It  has  appeared  to  me  for  some  time 
that  there  exists  some  relation  between  the  testicles  and  sebaceous  glands  in 
the  male,  as  there  does  between  the  automatic  menstrual  ganglia  and  seba- 
ceous glands  in  the  female. 

Whether  the  rut  (oestrus)  of  animals  and  the  menstruation  of  woman  are 
the  same  or  different  processes  we  will  not  discuss  now.  But  the  function 
of  the  ganglia  and  their  actual  rhythmic  process  would  be  precisely  the  same 
in  either  case.  In  mammals  an  oviductal  rhythm  with  its  associated  changes 
is  almost  a  necessity  to  transport  an  ovum  from  ovary  to  uterus.  I  could 
not  observe  any  difference  between  the  state  of  the  oviduct  and  the  relation 
of  its  mouth  to  the  ovary  in  animals  in  rut  and  the  menstrual  process  of 
woman.     The  gross  anatomy  of  both  processes  appeared  identical. 

Premenstrual  Pain. — The  pain  immediately  preceding  menstruation  is 
generally  not  well  understood.  I  have  observed  that  many  gynecologists  of 
the  present  day  attribute  the  premenstrual  pain  to  the  uterus.  They  say  the 
pain  is  due  to  the  mechanical  obstruction  to  the  menstrual  fluid.  These 
views  may  apply  to  certain  cases.  But  I  maintain  that  the  premenstrual 
pain  is  due  to  an  excessive  action  of  the  oviducts  or  a  too  vigorous  rhythm. 


AUTOMATIC  MENSTRUAL  GANGLIA  249 

The  automatic  menstrual  ganglia  are  overexcited  and  act  irregularly.  The 
excessive  stimulation  arises  mainly  from  the  fluid  which  finds  its  way  into 
the  lumen  of  the  oviduct.  The  fluid  in  the  lumen  of  the  oviduct,  arising  out 
of  its  congested  state,  acts  like  a  foreign  body  and  excites  oviductal  action. 
The  ganglia  become  immoderately  excited  in  oviducts  whose  lumen  is 
partially  or  wholly  closed.  The  vigorous  attempts  of  the  oviducts  to  expel 
the  fluid  confined  in  their  lumen  produce  well-known  agonizing  pain.  I  have 
examined  women  with  distended  oviducts  who  would  repeatedly  tell  me  that 
the  pain  excited  by  the  examination  would  last  for  hours.  The  oviducts 
were  simply  excited  into  peristalsis  by  irritation  of  their  ganglia. 

Dyspareunia,  so  frequent  in  oviductal  disease,  is  not  merely  a  story  of 
pain  at  the  time  of  connection,  but  of  pain  that  endures  for  hours.  Part  of 
the  pain  is  due  to  trauma  of  irritable  nerves,  but  the  worst  pain  is  caused  by 
setting  in  motion  the  vermicular  action  of  the  diseased  oviduct.  The  con- 
fined fluid  in  the  oviducts  excites  them  into  peristalsis,  just  as  irritating 
substances  excite  the  intestine  into  painful  peristalsis.  If  an  intestine, 
through  obstruction,  cannot  expel  its  irritating  contents,  the  picture  of  pain 
is  almost  identical  with  premenstrual  pain.  In  fact,  I  have  often  wondered 
whether  I  was  dealing  with  intestinal  or  oviductal  colic.  It  must  be  remem- 
bered that  muscle,  governed  by  sympathetic  ganglia,  acts  quite  differently 
from  muscle  governed  by  spinal  nerves.  One  is  slow  and  rhythmic,  while 
the  other  is  rapid  and  more  spasmodic. 

The  pelvic  brain  (cervico-uterine  ganglion)  is  a  large  mass  of  aggregated 
sympathetic  ganglia  situated  on  each  side  of  the  pelvis  at  the  junction  of  the 
uterus  and  cervix.  It  doubtless  shares  with  the  abdominal  brain  in  originat- 
ing, sustaining  and  inhibiting  the  menstrual  rhythm.  The  pelvic  brain,  like 
the  cervical  ganglia,  or  that  of  Wrisberg,  occupies  a  subordinate  position  in 
rgard  to  the  abdominal  brain.  It  is,  however,  a  prevertebral  ganglion.  It 
is  not  easy  to  dissect  and  isolate  on  account  of  its  white  color  and  resemblance 
to  adjacent  tissue.  It  is  three-quarters  of  an  inch  long  and  one-half  an  inch 
wide  in  some  subjects,  and  is  more  like  a  meshwork  than  the  abdominal  brain. 
Its  irregular  meshes  are  pierced  by  numerous  blood  and  lymph  vessels  and 
connective  tissue  bundles.  No  doubt  the  irritable  uterus,  which  Gooch 
described  seventy-five  years  ago,  is  caused  in  a  great  measure  by  an  irritable 
pelvic  brain.  A  rhythm  produced  by  a  ganglion  alone  is  a  very  delicate 
mechanism,  and  it  is  no  wonder  that  during  the  many  vicissitudes  of  menstrual 
life  the  rhythm  becomes  disturbed,  irregular  and  refuses  to  act.  Pressure  of 
the  increasing  size  of  the  child's  head  on  the  cervico-uterine  ganglion 
initiati  s  labor. 

.  natomical. — The  distribution  of  the  sympathetic  nerve  supply  and  the 
spinal  n  rve  supply  to  the  uterus  and  oviducts  strengthens  the  theory7  of 
automatic  menstrual  ganglia.  Anatomists  agree  that  the  uterine  sympathetic 
plexus  branches  off  to  supply  the  uterus  and  oviducts  above  the  point  where 
the  sacral  spinal  nerves  join  the  sympathetic  chain.  The  sympathetic  plexus 
of  nerves  with  its  ganglia  supplies  the  upper  portion  (body  and  fundus)  of 
the  uterus  and    the  whole  of    the  oviducts,  while  the  sacral    spinal  nerves 


250  THE  ABDOMINAL  AND  PELVIC  BRAIN 

mainly  go  to  the  cervix.  Now,  it  is  very  likely  that  the  (sacral)  spinal  nerves 
have  little  to  do  with  any  rhythm  or  cyclical  action.  It  is  quite  probable 
that  they  hinder  rhythm. 

They  would  thus  influence  the  cervix  to  live  a  steady  life.  The  ganglia 
on  the  sympathetic  uterine  and  oviductal  plexus,  on  the  other  hand,  are 
possessed  of  a  peculiar  property  called  rhythm,  so  their  ganglia  would 
endow  the  uterus  and  oviducts  with  rhythm.  This  agrees  with  the  observa- 
tion that  the  body  and  fundus  of  the  uterus  and  the  oviducts  are  the  main 
part  of  the  genital  tract  involved  in  menstruation,  while  the  cervix  and 
vagina,  mainly  supplied  with  spinal  nerves,  remain  fairly  still.  The  cervix 
is  a  mere  guard  to  the  uterus,  and  does  not  s*hare  in  menstruation.  These 
ganglia  mainly  follow  the  blood-vessels,  and  the  tortuous  helicoid  arteries 
supplying  the  uterus  and  oviducts,  which,  being  long,  give  much  space  for 
ganglia  to  exist.  The  ganglia  no  doubt  control  blood-supply  by  regulating 
the  caliber  of  the  artery  and  the  stay  of  the  blood  in  the  veins. 

3.  The  microscope,  or  sometimes  a  strong  lens,  will  demonstrate  the 
existence  of  the  ganglia  on  the  plexus  of  nerves  going  to  the  uterus  and  the 
oviducts.  The  nerves  show  uneveness.  At  places  they  coalesce  into  masses, 
and  the  microscope  demonstrates  their  ganglionic  character.  I  have  fre- 
quently been  able  to  trace  the  nerves  showing  distinct  bulbs  on  the  posterior 
part  of  the  uterus.  Histologists  have  some  time  ago  shown  that  little  gang- 
lia exist  in  the  walls  of  the  uteri  of  animals.  But  space  forbids  further 
discussion  here.  Every  visceral  organ  has  its  own  supply  of  sympathetic 
ganglia  brought  to  it  on  the  walls  of  the  blood-vessels.  Each  visceral  organ 
requring  it  has  its  own  established  cycle  initiated  in  primordial  life.  The 
rhythm  becomes  strengthened  by  differentiation  into  special  organs,  and  by 
repetition. 

It  seems  to  me  that  knowledge  of  the  various  visceral  ganglia  will  render 
the  function  of  those  organs  and  their  diseases  more  intelligible.  To  intelli- 
gibly minister  to  an  organ  diseased  one  must  know  its  pathology.  The 
treatment  of  any  disease  comprehends  part  if  not  all  of  its  pathology.  To 
me  the  action  of  the  heart  under  varying  states  and  pressure  of  the  blood  is 
more  intelligible  with  some  knowledge  of  the  automatic  ganglia  which 
control  its  rhythm  and  motion.  A  knowledge  of  the  functions  of  the  cardiac 
ganglia  clears  many  an  obscure  problem  and  explains  the  heart's  action 
under  varying  conditions.  The  same  may  be  said  of  the'ganglia  of  Meissner 
and  Auerbach  in  rendering  intestinal  peristalsis  intelligible.  So  a  study  of 
what  may  be  termed  the  automatic  menstrual  ganglia  will  perhaps  throw 
more  light  on  the  action  of  the  oviducts  and  uterus — organs  around  which 
woman  is  built  both  mentally  and  physically.  We  suggest  that  the  rhythmic 
function  of  the  endometric  gland,  its  nidation  and  denidation,  should  not  be 
neglected  as  a  part  of  menstruation. 

The  ganglia  in  the  uterus  and  oviducts  of  woman  generally  induce  a  cycle 
once  a  month  during  their  functional  activity.  The  ganglia  explode  monthly. 
In  the  lower  animals  the  automatic  uterine  and  oviductal  ganglia  explode 
in  periods  which  correspond  to  the  cycle  of  the  rut.     It  is  here  concluded 


AUTOMATIC  MRNSTRU.IL  GANGLIA  251 

that  whether  rut  and  menstruation  be  the  same  or  different  processes,  they 
are  governed  in  their  rhythm  by  the  automatic  uterine  and  oviductal  ganglia. 

Will  these  automatic  ganglia  aid  in  explaining  the  function  of  the 
uterus,  oviducts  or  ovary  after  surgical  or  other  destructive  procedures  on 
any  one  of  the  three?  I  think  they  will.  That  menstruation  is  closely  con- 
nected with  the  nervous  system,  and  that,  too,  with  the  sympathetic  (as  it 
has  rhythm)  is  a  common  observation.  Nerve  disturbances  disturb  menstrua- 
tion and  its  rhythm.  A  sprain  in  the  wrist  has  checked  menstruation.  I  knew 
a  patient  who,  while  menstruating,  became  frightened  by  a  whistle  from  a 
train  and  did  not  menstruate  for  a  year.  Sudden  changes  in  temperature 
will  alter  its  rhythm.  The  mere  expectation  of  marriage  will  occasionally 
make  its  rhythm  regular.  Marriage,-  by  mental  and  physical  stimulation 
to  the  genital  apparatus,  will  often  induce  regular  menstruation.  When 
the  nervous  system  is  impaired  in  strength  by  wasting  disease,  there  may 
not  be  enough  vital  energy  to  induce  and  sustain  menstrual  rhythms. 
Tubercular  girls  cease  to  menstruate.  It  is  a  common  observation  that  fleshy 
persons  have  weak  resisting  powers,  and  fleshy  women  often  menstruate 
irregularly.  In  a  precocious,  abnormally  developed  girl  we  may  see  early 
menstruation.  In  pregnancy  and  nursing,  menstruation  is  arrested  because 
the  nervous  vitality  is  expended  in  nourishment.  The  miserable  and  painful 
failure  of  an  infantile  uterus  in  menstration  is  rather  from  a  deficient  endome- 
trium. If  vital  energies  are  directed  into  different  channels,  or  vitality  gets 
to  a  low  ebb,  the  remaining  powers  may  be  insufficient  to  initiate  and 
sustain  the  regular  menstrual  rhythm.  Non-development  occurred  from 
insufficient  blood. 

From  the  views  entertained  in  this  paper,  that  menstruation  and  ovula- 
tion are  separate  processes,  and  that  the  automatic  ganglia  are  situated  along 
the  oviducts  and  uterus  and  probably  closely  related  with  the  ovary,  it 
would  not  be  expected  that  removal  of  the  ovaries  would  always  cause  men- 
struation to  cease  suddenly.  The  automatic  ganglia  of  the  oviducts  and  the 
uterus  are  still  intact  and  will  execute  their  rhythm.  Many  gynecologists 
testify  that  this  theory  agrees  with  the  facts.  Ovaries  are  extirpated  and 
oviductal  motion  continues.  However,  the  destruction  of  a  part  of  a  con- 
nected complex  organ  soon  destroys  the  nice  balance,  and  nourishment  of 
the  ganglia  would  in  time  deteriorate,  and  then  insufficient  nerve  vitality 
with  lack  of  ganglionic  harmony  would  fail  in  starting  and  maintaining  a 
menstrual  rhythm.  Also,  it  may  be  considered  that  the  chief,  central,  sexual 
organ  of  woman  is  the  ovary  and  the  uterus  and  oviducts  are  appendages  of 
the  ovary.  Extirpation  of  the  oviducts  would  quite  effectually  aid  in  arresting 
menstruation,  though  not  entirely,  as  many  ganglia  would  remain  in  the 
uterine  wall.  Yet  in  the  very  plan  of  the  machinery  the  oviduct  is  no  doubt 
designed  to  execute  more  motion  than  the  uterus,  which  could  perform  its 
function  while  remaining  quite  still.  By  the  German  gynecologists,  during 
several  years'  residence  abroad,  I  was  informed  that  a  removal  of  the  ovi- 
ducts in  a  vast  majority  of  cases  caused  a  rapid  checking  of  menstruation. 
Mr.   Lawson  Tait  writes  that  the  total  removal  of  the  oviducts  arrests  men- 


252  THE  ABDOMINAL  AND  PELVIC  BRAIN 

struation  in  90  per  cent  of  cases.  Is  it  not  strange  that  an  oviduct  cut  off 
two  inches  from  the  uterus  will  maintain  the  rhythm?  Actual  cases  prove 
that  when  only  the  diseased  ovaries  are  removed  from  women,  with  inflam- 
mation existing  in  the  oviducts,  they  are  but  little  helped  in  their  misery. 
The  active  organ  in  menstruation  is  the  oviduct,  and  it  will  execute  its 
rhythm  unless  removed.  Ligating  the  oviducts  is  not  a  rational  method,  as 
it  will  not  check  the  rhythm.  Nine  years  ago  I  began  ligating  the  uterine 
artery  at  the  neck  of  the  uterus  after  removing  its  appendages.  This  effect- 
ually and  immediately  checked  menstruation  and  rapidly  atrophied  the  organ. 

Finally,  the  oviducts  and  most  of  the  uterus  being  removed,  menstruation 
will  nearly  always  stop.  The  ovary,  left  without  an  oviduct,  would  not 
sustain  menstruation.  Cases  are  reported  where  the  oviducts  and  ovaries 
and  most  of  the  uterus  were  removed,  but  menstruation  continued.  In  such 
cases,  no  doubt,  a  sufficient  number  of  automatic  ganglia  were  left  to  start 
and  sustain  a  menstrual  rhythm.  In  such  cases  I  suggest  that  investigation 
of  total  removal  of  the  organs  and  also  of  the  reality  of  continued  menstrua- 
tion should  be  carefully  done.     Patients  often  call  any  bleeding  menstruation. 

The  ovary  is  the  central,  essential,  sexual  organ  of  woman  (requisite  not 
only  for  ovulation  but  internal  secretion)  and  should  be  removed  for  malig- 
nancy and  grave  disease  only. 

Other  theories  have  been  advanced  as  to  the  cause  of  menstruation. 
Dr.  Christopher  Martin  claims  that  the  nerve  centers  are  located  in  the 
lumbar  cord.  This  is  doubtless  based  on  the  labors  of  Budge,  who  located 
the  center  of  the  bladder  in  the  lumbar  cord. 

I  wish  to  thank  Dr.  C.  S.  Miller,  of  Toledo,  Ohio,  who  worked  long  with 
me  on  this  subject. 


CHAPTER   XXI. 

MENOPAUSE. 

"Nature  has  caprices  which  art  cannot  imitate." — Macaulay. 

Mcnstruatio  precox  is  followed  by  climacterium  retardum.u 

The  vagina  has  tzvo  sphincters,  viz.:  (a)  o?ie,  the  internal,  ruled  by  the 
sympathetic ;  (b)  the  other,  the  external,  dominated  by  the  spinal  nerves. 

The  menopause  ends  slowly,  as  puberty  begins.  It  is  frequently  difficult 
to  decide  which  produces  the  most  profound  impression  on  the  general 
system.  The  popular  belief  is  that  the  period  of  menopause  is  a  time  of 
danger  to  woman.  It  is  claimed  that  she  is  more  liable  to  malignant  growths 
of  the  genital  organs  or  the  breasts,  and  the  average  woman  expects  disturb- 
ances to  arise,  either  bodily  or  mentally.  Popular  belief  that  woman  is  more 
liable  to  disease  at  the  menopause  is  probably  correct. 

The  symptoms  of  the  menopause  are:  (a)  cessation  of  the  monthly  flow, 
(b)  flashes  of  heat,  (c)  flashes  of  circulation,  (d)  irregular  perspiration.  The 
cessation  of  the  flow  is  a  very  irregular  and  indefinite  matter,  but  generally 
occurs  at  about  45  years  of  age.  It  requires  an  average  of  eighteen  months 
for  menstruation  to  become  regularly  established;  besides,  the  genitals  were 
being  prepared  for  several  years.  It  requires  two  and  one-half  years  for  the 
monthly  flow  to  cease,  on  an  average.  The  flow  ceases  very  irregularly, 
even  in  normally  physiologic  cases.  The  flow  may  be  scant  one  month,  not 
appear  at  all  the  next,  and  the  third  or  fourth  a  flooding  may  occur.  Should 
the  flow  cease  without  pathologic  manifestations?  I  would  answer  "No. " 
Many  no  doubt  will  oppose  this  view  and  say  that  it  is  a  purely  physiologic 
process,  but  it  is  frequently  accompanied  by  ailments.  So  is  labor  a  physi- 
ologic process,  but  it  is  frequently  accompanied  by  pain  and  other  disturb- 
ances. The  cessation  of  menstruation  means  the  death  of  a  great  function, 
the  atrophy  of  a  dominating  organ  which  has  the  greatest  nerve  supply  of  all 
the  viscera. 

The  beginning  of  puberty  shows  vast  changes  in  the  entire  vascular 
system  and  also  much  change  in  the  whole  sympathetic,  besides  the  field  of 
nutrition.  The  most  manifest  change  at  puberty  is  shown  by  a  perturbed 
nervous  system. 

The  nervous  apparatus  of  the  visceral  organs  may  well  be  compared  to 
the  equalizers  on  the  horse-power  of  a  threshing  machine.  When  the  ten 
horses  pull  evenly  the  gearing  works  uniformly,  but  the  neglect  of  one  team 
puts  the  gearing  awry,  and  though  the  machine  may  run,  its  working  is  not 
of  such  fine  balance.  The  destruction  of  one  function  in  a  well-balanced 
nervous  system  is  sure  to  destroy  the  well-established  balance  in  the  others, 

253 


254 


THE  ABDOMINAL  AXD  PELVIC  BRAIX 


so  that  in  my  opinion  pathologic  disturbances  may  be  looked  for  at  the 
menopause.  In  order  to  make  my  views  clear  and  reasonable,  let  us  con- 
struct a  diagram  of  the  sympathetic  system.  The  accompanying  cut  (fig. 
59)  represents  the  sympathetic  nerves.  It  is  drawn  in  the  form  of  an 
elongated  ellipse.  At  the  upper  end  of  the  ellipse  begins  the  cerebral  com- 
municating artery  at  the  so-called  ganglion  of  Ribes.  The  lower  end  of  the 
ellipse  ends  at  the  coccyx  or  ganglion  impar.  '"re"  shows  the  connection 
of  this  ellipse  with  the  cerebro-spinal  axis.     The  interior  of  this  ellipse  is  of 


A  SCHEMATIC  DRAWING  OF  THE  SYMPATHETIC  NERVE 

Fig.  59.  X,  ganglion  of  Ribes.  Y,  coccygeal  ganglion  (impar).  L.,  liver.  K,  kidney. 
S.,  spleen.  Sp.  P.,  (spermatic)  ovarian  plexus.  I.,  intestine.  A.  B.,  abdominal  brain  (center 
of  reorganization).  Sp.  N.,  splanchnic  nerves.  C.  N.,  cardiac  nerves.  H.  P.,  hypogastric 
(aortic)  plexus  (coming  from  three  sources).  U.,  uterus,  oviducts  and  ovaries.  H.,  heart. 
C.  G.,  the  three  cervical  ganglion  (secondary  center  of  reorganization). 

The  sides  of  the  ellipse  represent  the  lateral  chain  of  the  sympathetic.  One  nerve  strand 
goes  from  the  abdominal  brain  (a.  b.)  to  each  viscus  to  represent  its  plexus.  Observe  that 
the  spermatic  plexus  (sp.  p.)  arises  from  the  abdominal  brain,  renal  plexus  and  aortic  plexus. 
Any  irritation  starting  in  any  viscus  will  pass  to  the  abdominal  brain,  where  reorganization 
occurs,  and  the  forces  are  redistributed  over  the  plexuses  to  every  viscus. 


MENOPAUSE  255 

special  interest,  for  here  lies  the  vast  and  complicated  network  of  this 
nervous  ring,  "ab"  indicates  the  abdominal  brain,  solar  plexus  or  semilunar 
ganglia — the  center  or  reorganizing  locality  of  the  sympathetic  system.  From 
this  abdominal  brain,  renal  ganglia  and  the  lateral  sympathetic  chain, 
passes  off  a  large  plexus  of  nerves,  down  the  aorta  to  the  uterus,  oviducts  and 
ovaries.  This  is  known  as  the  hypogastric  plexus.  The  observation  which  I 
note  in  the  dissection  of  quite  a  number  of  old  women  is,  that  after  the 
menopause  the  genitals  not  only  atrophy,  but  the  hypogastric  plexus  also 
shrinks. 

However,  the  abdominal  brain  does  not  atrophy.  It  retains  its  function 
and  structure  to  the  end  of  life.  Dr.  Adolph  Meyer,  formerly  of  Chicago 
University,  now  in  Worcester,  Mass.,  writes  me  the  following  letter,  which 
explains  itself: 

The  Worcester  Lunatic  Asylum. 
Worcester,  Mass.,  Feb.  20,  1896. 
My  Dear  Dr.  Robinson: — 

Nearly  two  years  ago  you  asked  me  to  give  you  some  specimens  of  a 
sympathetic  ganglion,  to  ascertain  that  it  is  not  a  degenerate  organ,  but  a 
living  organ  with  numerous  ganglion  cells.  Those  of  your  opponents  who 
would  not  believe  this  may  see  this  specimen  from  a  woman  of  74,  who  had 
been  insane  thirty  years,  and  died  of  heart  rupture.  The  ganglion  cells  of 
the  semilunar  ganglion  are  large,  numerous,  moderately  pigmented  (not  more 
than  the  spinal  ganglia  and  other  nerve  cells). 

Adolph  Meyer. 

The  hypogastric  plexus  becomes  smaller,  finer  and  no  doubt  some  strands 
disappear  at  the  beginning  of  the  menopause.  On  this  fact  must  be  based  the 
pathologic  symptoms  accompanying  the  cessation  of  the  menstrual  function. 
In  dissecting  infants  which  have  lain  in  alcohol  for  some  six  weeks,  the  very 
opposite  condition  of  the  hypogastric  plexus  may  be  observed,  for  in  the 
young  child  the  hypogastric  (sympathetic)  plexus  is  disproportionately  large 
and  can  be  very  plainly  dissected  out.  The  explanations  of  the  disturbances 
of  the  menopause  may  be  shown  as  follows:  For  thirty  years  monthly 
rhythmic  impulses  have  passed  over  the  hypogastric  plexus  to  the  uterus  and 
oviducts.  A  fixed  habit  has  been  established  and  the  genital  organs  lie  in 
the  sensory  and  motor  grasp  of  the  hypogastric  plexus.  The  importance 
of  the  genital  organs  is  shown  by  the  vast  nerve  supply  sent  to  them  and  also 
because  the  hypogastric  originates  in  great  central  sources.  It  arises  plainly 
from  the  abdominal  brain,  the  renal  plexus  and  sympathetic  lateral  chain. 
It  is  intimately  and  closely  associated  with  the  whole  sympathetic  ellipse. 
Now  when  this  great  nerve  tract,  known  as  the  hypogastric  plexus,  will  not 
transmit  the  higher  physiologic  orders,  it  will  unbalance  all  other  parts  of 
the  ellipse.  If  the  nervous  forces  cannot  go  over  an  old-established  line 
they  will  go  over  the  next  line  of  least  resistance.  The  hypogastric  plexus 
cannot  carry  the  orders  as  it  is  atrophied  and  destroyed  for  the  old  work. 
Monthly  rhythm  of  thirty  years  established  in  the  abdominal  brain  is  not  to 
die  without  a  struggle.     This  explanation  will  enable  us  to  understand  the 


256  THE  ABD0M1XAL  AXD  PELVIC  BRAIN 

many  pathologic  manifestations  of  every  viscus  at  the  menopause.  The 
irritation  which  arose  by  trying  to  pass  more  nervous  impulses  over  plexuses 
than  normal,  gives  origin  to  what  is  unfortunately  known  as  "functional 
disease.-'  It  is  just  as  organic  as  any  disease,  only  we  are  not  able  to  detect 
it.  Acute  atrophy  is  a  pathologic  condition  and  no  doubt  this  is  the  condi- 
tion of  the  hypogastric  plexus  at  the  menopause.  The  sudden  assumption 
of  function  of  the  hypogastric  plexus  at  puberty  produces  similar  disturb- 
ances, only  the>"  do  not  assume  such  definite  symptoms  as  at  the  menopause. 
The  young  woman  has  more  depression  than  the  woman  in  menopause, 
unless  her  ovaries  be  diseased.  The  advent  of  menstruation  is  an  important 
feature    in  the  life  of  woman. 

After  the  cessation  of  the  flow  the  most  prominent  symptom  is  what  is 
called  flushes.  Over  eight}'  per  cent,  of  women  will  experience  this  peculiar 
phenomenon  at  the  menopause.  Two  distinct  propositions  will  explain  this 
subject:  Flushes  result  from  a  disturbance  of  the  vaso-motor  centers,  and 
flashes  from  irritation  of  the  heat  centers.  Heat  and  circulative  disturbances 
are  so  intimate  and  go  together  so  frequently  that  I  shall  not  attempt  to 
describe  them  separately.  The  heart  and  vaso-motor  centers  are  unbalanced 
by  irritation  at  the  menopause.  The  hot  flashes  may  come  on  rapidly  and 
irregularly  for  a  short  period,  and  then  remain  away  for  days.  The  patient 
indicates  that  the  disturbances  are  first  manifest  near  the  stomach,  and  then 
rapidly  spread  over  the  head  and  chest.  It  would  seem  from  carefully 
watching  these  manifestations  at  the  menopause  that  wave  after  wave 
succeeds  each  other.  I  have  watched  them  under  attacks  and  they  seem  to 
be  under  a  desperate  struggle  to  control  themselves.  The  blood-vessels  of 
the  head  and  neck  appear  most  affected,  yet  the  skin  of  the  whole  body 
shares  in  the  disturbance.  The  nerve  impulse,  which  should  be  emitted 
along  the  hypogastric  plexus,  is  abnormally  forced  over  other  plexuses  and 
the  vaso-motor  becomes  irritated,  resulting  in  dilatation  and  contraction  of 
the  peripheral  vessels.  All  molecular  action  generates  heat,  and  it  may  be 
that  much  of  the  heat  experienced  is  due  to  the  rapid  dilatation  of  the  vast 
number  of  vessels  and  the  rapid  flow  of  fresh  blood  in  them.  As  the  cheeks 
glow  the  patient  experiences  sudden  heat,  the  skin  grows  red  with  flushing 
blood.  Besides  the  disturbance  of  the  vaso-motor  and  the  heat  center, 
the  sweat  center  is  also  irritated,  the  flushes  and  flashes  followed  by 
various  degrees  of  sweating.  This  is  just  as  irregular  and  uncertain.  The 
quantities  of  sweat  vary  from  a  fine  moisture  to  great  drops.  It  is  apparent 
to  any  ordinary  observer  that  profound  disturbances  arise  at  both  puberty 
and  menopause  and  it  is  not  strange  that  tradition  attributes  some  diseases 
to  the  advent  of  puberty  and  many  grave  conditions  to  the  menopause. 

The  theory  of  disease  at  the  menopause  must  rest  on  the  unbalancing  of 
the  nervous  system  by  changing  the  old  established  nerve  channel  through 
which  they  have  carried  impulses  for  a  generation.  It  must  rest  on  actually 
diseased  genitals,  or  atrophy  of  the  organs  on  the  plexuses  which  transmit 
controlling  forces  to  them.  Disease  at  the  menopause  must  rest  on  some 
irritating  center,  which  is  chiefly  the  genitals  and  their  nerves.      Like  many 


CLIMACTERIUM  257 

old  gynecologists,  we  need  not  look  for  the  sole  cause  in  the  ovaries,  but  the 
trouble  is  due  to  reflex  irritation.  Eighty  per  cent  of  such  women  suffer  in 
general  from  nervous  irritability.  Fifty  per  cent,  have  disturbance  in  the 
heat  and  circulatory  centers.  Probably  iifty  per  cent,  suffer  deranged  sensa- 
tions, hyperesthesia  and  anesthesia.  Perhaps  forty  per  cent,  of  women  at 
the  menopause  suffer  from  the  headache,  abdominal  pain  and  perspiration. 
About  twenty-live  per  cent,  of  women  at  the  menopause  suffer  from  leucor- 
rhea,  sudden  flooding  and  sweats.  This  means  that  all  the  secretory  apparatus 
of  the  skin,  mucous  membrane  and  centers  are  deranged.  The  first  thing  to 
suspect  in  such  patients  is  deceased  genitals.  Endometritis  is  an  arch  fiend 
at  this  period  in  a  woman's  menstrual  life. 

Inflammation  of  some  kind  may  be  found  in  the  uterus,  oviducts  and 
ovaries.  Acute  atrophy — a  form  of  degeneration  or  malnutrition — must  be 
recorded  among  the  diseases.  If  no  pelvic  trouble  be  found,  the  whole 
abdomen  and  chest  must  be  examined  for  some  disorder.  I  have  found  that 
the  glycerin  tampon  twice  weekly,  and  the  hot  douche  gradually  increased 
to  ten  quarts  twice  daily,  often  cures  such  patients,  at  least  symptomatically. 
Curetting  may  be  required  in  a  limited  few,  however  it  is  not  so  dangerous 
in  the  menopautic  as  in  the  young  woman  on  account  of  atrophy  and  conse- 
quent inability  to  receive  infection.  Radical  disturbances  in  the  menopause 
mean  disease,  and  generally  it  is  located  in  the  pelvis.  Women  are  expected 
to  suffer  from  neuralgia  at  this  time,  nerve  irritation,  but  their  intellect  is 
also  often  disturbed,  especially  in  the  will  power.  General  treatment 
especially  visceral  drainage  is  right  and  reasonable,  with  baths  and  attention 
to  food  and  evacuations.  The  patients  fret  and  worry  and  do  not  rest  or 
sleep  well.  The  bromides  act  well,  especially  given  at  night.  I  make  over 
half  the  dose  sodium  bromide,  as  that  does  not  irritate  the  skin  so  much  as 
potassium  bromide.  The  bowels  are  best  regulated  by  a  glass  of  water  each 
night  at  bed-time,  in  which  there  is  from  one-half  to  one  dram  of  epsom 
salt;  with  the  additional  advice  to  go  to  stool  every  morning  immediately 
after  breakfast,  i.  e.,  after  the  hot  coffee  has  stimulated  peristalsis  of  the 
bowel. 

It  is  traditional  that  women  become  like  men  after  the  menopause  and 
it  is  common  for  women  to  argue  against  removal  of  the  ovaries,  fearing 
that  hair  will  grow  on  the  face  and  that  they  will  become  mannish.  Flesh 
may  increase  because  of  disappearing  disturbances.  It  is  common  for 
women  to  take  on  fat  at  the  menopause.  This  is  a  form  of  low-grade 
nutrition.  I  have  examined  at  least  half  a  dozen  patients  of  this  nature  who 
were  considered  subjects  of  tumors  or  pregnancy.  But  a  little  experience 
and  patience  will  prove  to  the  physician  that  the  tumor  consists  simply  in 
abnormally  thick  and  fleshy  belly  walls. 

No  one  can  number  the  many  and  varied  pains  that  attack  women  in  the 
menopause.  Most  of  the  pains  arise  around  the  stomach,  i.  e.,  in  the 
abdominal  brain — the  solar  plexus.  The  pains  which  originate  in  the 
epigastric  region  are  innumerable,  indefinable  and  baffle  all  systematic 
description.     We  must,  however,  have  charity  sufficient  to  allow  that  these 

17  


258  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

numberless  disturbances  are  real  to  the  sufferer.  The  "something  moving 
in  the  stomach"  ma)'  be  abnormal  peristalsis,  induced  by  a  diseased  focus, 
as  in  the  globus  hystericus.  Whatever  opinion  is  held  by  the  physician,  a 
reasonable  treatment  should  be  introduced.  Such  patients  have  so  little 
confidences  in  themselves,  their  physician  and  their  friends,  that  they  have 
not  the  will  power  to  persist  a  systematic  course  of  treatment.  Hence  they 
go  around  from  one  physician  to  another.  The  duty  of  the  physician  is  to 
locate  the  disease  and  attempt  to  restore  order  in  a  disordered  sympathetic 
nervous  system,  which  becomes  unbalanced  by  reason  of  some  irritation 
arising  from  atrophy,  senility  and  inflammation.  A  thorough  automatic  and 
physiologic  knowledge  of  the  sympathetic  nervous  system  is  required  for 
intelligent  practice  in  gynecology.  The  pathologic  condition  must  be  found 
in  order  to  show  skill  in  removing  it.  It  must  be  remembered  that  a  stormy 
puberty  generally  means  a  stormy  menopause.  If  a  girl  begins  menstruation 
with  pain  and  disturbance  it  generally  means  diseased  genitals — oviducts  or 
uterus  probably — and  the  sympathetic  system  will  suffer. 

The  intimate  and  wide  connection  of  the  nervous  system  and  genitals  is 
phenomenal.  The  nervous  connection  of  the  genitals  is  profound  and  any 
genital  trouble  deeply  impresses  the  whole  system.  It  would  not  be  strange, 
also,  if  one  uterus  were  found  with  vastly  more  nervous  connections  than 
another,  or  that  is,  at  least,  much  more  sensitive  than  others.  My  experi- 
ence in  the  dead-house,  as  well  as  observation  in  the  living,  is  that  viscera 
vary  much  in  size.  In  some  the  uterus  is  small,  in  others  large,  without 
regard  to  the  individual  stature. 

Menstruation  must  be  looked  upon  as  arising  and  subsiding  in  the 
nervous  system,  especially  in  the  sympathetic  system.  I  would  like  to  make 
a  plea  for  more  study  of  the  nervous  system,  and  particularly  the  visceral 
nervous  system.  From  the  lack  of  this  knowledge  physicians  are  constantly 
mistaking  nervous  diseases  for  uterine  disease.  A  great  evil  is  going  on  toda3' 
in  regard  to  the  misunderstanding,  that  a  little  nervousness  does  not  always 
belong  to  the  ovaries  or  uterus.  The  nervous  system  is  a  vast,  finely- 
ordered,  nicely-balanced  machine,  which  can  be  easily  disordered  without 
the  least  need  of  removing  the  ovary,  uterus  or  oviduct.  Some  general  or 
local  treatment  may  be  amply  sufficient.  Too  many  laparotomies  are  being 
done  today  by  unskilled  men  without  proper  facilities.  Sweeping  removal 
of  organs  is  a  backward  step  in  surgery,  and  the  general  disapprobation  of 
the  leading  gynecologic  surgeons  must  cry  it  down.  It  must  be  insisted  that 
he  who  would  work  in  the  peritoneal  cavity  must  be  trained.  Training  and 
skill,  coupled  with  a  decent  sense  of  right,  will  alone  stand  the  test  of  time 
in  any  branch  of  surgery.  The  colleges  must  begin  with  chairs  of  anatomy 
and  abdominal  experiments  for  small  classes.  A  large  plea  should  be  entered 
for  an  attempt  to  understand  the  pathology  of  the  sympathetic  nervous 
system,  i.  e.,  visceral  nervous  system. 

A  pathologic  state  is  one  manifesting  abnormal  conditions,  whether 
they  are  recognizable  changes  in  structure,  or  simple  deranged  functions 
without  perceptible  disordered  structure.       There  are   reflex   neuroses,    by 


MENOPAUSE  259 

which  I  mean  disturbances  in  distant  parts  produced  by  irritation  of  some 
sensor}'  or  motor-peripheral  area.  It  is  easy  to  note  that  a  woman  is  irri- 
table or  nervous,  without  in  the  least  being  able  to  locate  the  pathology  from 
which  the  disturbance  originated.  One  of  the  most  marked  features  of  the 
menopause  is  this  kind  of  nervous  irritability.  It  may  be  easily  observed 
that  women  in  the  menopause  do  not  suffer  from  tumors  and  malignant 
diseases  so  much  as  they  do  from  disturbance  in  the  sympathetic  system 
and  cerebrospinal  axis.  Nervous  irritability  characterizes  four  women  out 
of  five  during  the  menopause.  How  does  this  come  about?  Two  ideas 
explain  the  complicated  but  slow  course  of  the  disease,  viz.,  Reflex  irrita- 
tion and  malnutrition.  It  can  be  easily  seen  that  the  nervous  system  is  out 
of  balance  in  the  menopause.  The  beginning  and  end  of  menstruation  is  in 
the  sympathetic  nerves.  Puberty  is  heralded  by  ganglionic  rhythm  and  the 
menopause  comes  in  at  the  cessation  of  the  rhythm.  The  entrance  and 
disappearance  of  menstruation  are  nervous  phenomena.  The  genitals  then 
become  a  point  of  new  irritation  as  puberty  begins,  and  the  genitals  are 
again  the  focus  of  irritation  as  the  rhythm  departs  forever.  Menstrual 
starting  chafes  the  system  profoundly,  but  its  cessation  irritates  the  system 
notably  with  its  dying  struggles.  By  the  figure  it  is  plain  that  any  genital 
irritation  can  be  easily  carried  to  the  abdominal  brain  where  the  reorganiza- 
tion occurs.  The  newly  organized  force  will  go  to  every  viscus  in  the 
sympathetic  ellipse  and  damage  the  rhythm.  Now  the  visceral  rhythm  is 
fof  the  purpose  of  nutrition,  and  pursues  its  even  tenor  in  a  kind  of  orderly 
manner.  But  irritation  from  a  focus  never  comes  or  goes  by  rule.  It  goes 
at  all  times  and  any  time,  while  the  viscera  are  performing  their  nutritive 
rhythm.  The  irritation  from  the  diseased  focus  forces  itself  up  the  hypogas- 
tric plexus  to  the  organizing  center  and  is  emitted  to  all  viscera,  in  addition 
to  the  abdominal  nutrition  and  rhythm  and  disorders  natural  to  visceral 
rhythm.  Few  but  the  special  clinical  gynecologist  fully  recognize  that 
uterine  disease  is  often  such  a  slow  process  and  that  it  can  start  a  train  of 
evils. 

A  few  weeks  or  months  of  pelvic  irritation  gradually  produce  deranged 
visceral  rhythm  and  consequent  indigestion.  The  addition  of  indigestion 
to  a  diseased  visceral  focus  makes  a  double  burden  on  the  whole  system. 
The  nerves  become  more  irritable.  Indigestion  persists  and  soon  brings  on 
distinct  malnutrition — another  burden  to  the  ganglionic  system  of  nerves. 
All  this  continues  until  anemia  arises,  the  result  of  waste-laden  blood. 
Now  it  is  apparent  to  all,  when  waste-laden  blood  bathes  all  the  thousands 
of  ganglia  and  nerve  strands  in  the  body,  that  the  patient  becomes  nervous 
or  irritable.  The  sympathetic  ellipse  is  unbalanced  and  its  centers  are  dis- 
ordered. It  is  a  slow  process  for  a  woman  to  pass  from  a  single  focus  of 
visceral  disease  to  a  neurotic  condition.  The  whole  disturbance  becomes 
intelligible  by  comprehension  of  the  nervous  system  and  a  knowledge  of 
the  condition  of  the  diseased  genitals.  The  intelligent  practitioner  always 
examines  the  genitals  in  a  disordered  menopause.  A  stormy  menopause 
means    diseased    genitals.      It  means  a  focus  of  pathology  which  is  nearly 

■ 


260 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


always  situated  in  the  pelvis.  The  effects  on  the  individual  may  be  described 
by  noting  how  the  irritation  can  pass  up  the  hypo-gastric  plexus  to  the 
abdominal  brain  and  being  reorganized  be  emitted  to  the  digestive  tract. 
The  irritation  goes  on  day  and  night ;  when  it  reaches  the  digestive  canal  by 
way  of  the  gastric,  superior  and  inferior  mesenteric  plexus,  it  first  affects 
Auerbach's  ganglionic  plexus  of  nerves  which  lie  between  the  muscular 
layers  of  the  intestinal  wall.     This  simply  disturbs   peristalsis  and  induces 


LUMBAR  AND  SACRAL  PORTIONS  OF  THE  SYMPATHETIC  (SAPPEY) 

Fig.  60.  1,  cut  edge  of  diaphragm  ;  2,  lower  end  of  oesophagus  ;  3,  left  half  of  stomach  ; 
4,  small  intestine;  5,  sigmoid  flexure  of  the  colon;  6,  rectum ;  7,  bladder;  8,  prostate;  9, 
lower  end  of  left  vagus  ;  10,  lower  end  of  right  vagus  ;  11,  solar  plexus  ;  12,  lower  end  of  great 
splanchnic  nerve  ;  13,  lower  end  of  lesser  splanchnic  nerve  ;  14, 14,  two  last  thoracic  ganglia  ; 
15, 15,  the  four  lumbar  ganglia ;  16,  16, 17, 17,  branches  from  the  lumbar  ganglia ;  18,  superior 
mesenteric  plexus ;  19,  21,  22,  23,  aortic  lumbar  plexus ;  20,  inferior  mesenteric  plexus ;  24, 
24,  sacral  portion  of  the  sympathetic;  25,  25,  26,  26,  27,  27,  hypogastric  plexus;  28,29,30, 
tenth,  eleventh  and  twelfth  dorsal  nerves  :  31,  32,  33,  34,  35,  36,  37,  38,  39,  lumbar  and  sacral 
nerves. 


CLIMACTERIUM  261 

perhaps    some    colic.     But    as  the  irritation  passes  to  Meisner's    plexus   it 
disorders  secretion. 

Thus  the  great  assimilating  laboratory  of  life  is  deranged.  Digestive 
disorders  are  common  in  the  menopause.  Liver  disturbances  are  common. 
The  irritation  passes  through  the  abdominal  brain  to  the  liver,  inducing 
excessive,  deficient  or  disproportionate  bile,  glycogen  and  urea.  The  rhythm 
of  the  liver  is  deranged.  Its  rhythmical  activity  and  quiet  repose  are  con- 
tinually disturbed  by  reflex  irritation.  It  is  easy  to  observe  disease  of  the 
liver  from  the  condition  of  the  patient  in  menopause — skin  and  bowel  abnor- 
malities. The  route  from  the  genitals  to  the  heart  is  made  plain  by  the 
diagram.  The  irritation  from  the  diseased  genitals  passes  to  the  abdominal 
brain,  thence  up  the  splanchnics  to  the  three  cervical  ganglia,  whence  the 
reorganized  irritation  passes  to  the  heart  over  the  three  cardiac  nerves.  The 
result  is  that  the  heart  goes  rapidly,  irregularly — it  palpitates. 

After  nervous  irritability  the  woman  in  menopause  probably  suffers  most 
frequently  from  flushes  and  flashes,  i.  e.,  irritation  of  the  vaso-motor  and  heat 
centers.  Her  skin  glows  with  fresh  red  blood  or  burns  with  prickling  heat. 
This  seems  to  me  to  be  merely  an  unbalanced  condition  of  the  nervous  sys- 
tem due  to  a  disordered  focus.  The  transmission  goes  in  a  tumultuous  man- 
ner, over  roads  which  are  not  accustomed  to  so  much  vigorous  commerce  and 
the  centers  are  not  able  to  orderly  reorganize  it.  The  circulation  floods  or 
depletes  the  vaso-motor  centers. 

One  may  observe  that  some  women  enter  puberty  with  many  indescrib- 
able pains  and  they  continue  to  complain  of  peculiar  abdominal  pains  during 
the  reproductive  period,  and  at  menopause  they  simply  becomechronic  grum- 
blers and  complain  more  and  more  bitterly.  What  must  be  said  of  such 
women?  We  must  not  consider  them  as  fabricating  untruths  for  a  whole 
generation  we  must  attempt  to  study  the  ganglionic  system  of  the  sympa- 
thetic in  order  to  unravel  the  apparent  mystery.  We  may  say  that  women 
with  these  abdominal  pains  are  in  a  poor  state  of  nourishment.  Debility 
characterizes  the  ganglionic  disease  while  irritability  is  the  feature  of  cere- 
brospinal axis  pathology.  Women  with  ganglionic  diseases  are  weak,  ill- 
nourished  creatures,  often  unable  to  do  a  little  housework.  Can  we  not 
consider  that  such  patients  have  hyperesthesia  or  anesthesia  of  the  visceral 
ganglia?  The  ganglia  are  little  brains,  for  they  all  have  the  elements  of  the 
cranial  cerebrum,  — nerve  cells  and  processes.  In  short  every  nerve  cell  is  a 
unit  in  itself.  It  is  an  isolated  anatomic  unit,  a  neuron,  a  brain  and  a 
reorganizing  center.  The  essential  of  the  cell  is  the  nucleus  because  it  has 
the  power  of  nutrition,  hence  reproduction.  Hence  each  ganglion  is  a 
little  brain,  a  reorganizing  center. 

Now,  a  brain  or  ganglion  cell  receives  sensation,  emits  motion  and 
controls  nutrition.  It  reproduces  itself,  it  controls  secretion  and  lives  in 
balanced  relations  with  its  environment.  Can  we  not  think  that  such  patients 
have  over-sensitive  or  irritable  abdominal  brains?  Their  visceral  nerve 
apparatus  is  abnormal,  it  is  out  of  order.  But  this  center  holds  in  abeyance 
nerve  energy  and  nerve  force.     It  holds  all  the  assimilating  and  circulatory 


262  THE   ABDOMIX.IL   AND   PELVIC  BRAIX 

laboratory  in  living  tension.  Such  patients  have  not  a  perfect  machine 
with  which  to  work.  They  are  generally  congenitally  defective,  or  are 
made  so  by  the  acquisition  of  some  profound  function,  such  as  men- 
struation. The  female  visceral  nerves  seem  to  be  peculiarly  liable  to 
rapid  derangement.  Women  faint  easily  and  slight  occurrences  disorder 
their  viscera.  The  flying  of  a  bird  will  make  the  heart  palpitate.  A  sudden 
noise  deranges  respiration  or  circulation.  A  change  of  locality  either  corrects 
or  disorders  the  nervous  system.  The  female  nervous  system  is  much  more 
unstable  than  the  male,  and  no  doubt  that  is  the  reason  that  so  many 
physicians  mistake  nervous  disease  for  uterine  disease.  Such  physicians 
are  either  ignorant  of  the  delicate  nerve  mechanism  or  are  over-zealous 
operators. 

The  pathologic  condition  of  the  genital  organs  in  the  natural  menopause 
is  generally  atrophy,  absorption  of  fat  and  consequent  shrinkage,  lessened 
vascular  supply  and  consequent  smaller  organs.  It  is  a  pure  senile  atrophy. 
The  organs  assumed  action,  served  their  purpose  and  subsided  forever.  Even 
in  a  natural  menopause  the  distinct  dying  struggle  may  be  expected  in  the 
hypogastric  plexus.  Puberty  increases  the  volume  of  the  organs,  while 
menopause  lessens  it.  Puberty  is  the  real  birth  while  menopause  is  the  real 
death  of  the  female  genitals.  The  appearance  of  the  individual  organs  at 
the  menopause  is  peculiar.  The  pudendum  wrinkles  and  shrivels  through 
the  absorption  of  fat  and  other  tissues.  In  dissecting  senile  genitals  the 
pudendal  sac  of  Bichat  and  Savage  become  more  apparent  than  ever.  One 
can  push  the  index  finger  into  it  and  the  greater  labia  will  appear  and  feel 
very  thin,  while  the  sac  seems  disproportionately  large.  The  fat,  rounded 
form  of  youth  obscures  this  peculiar  pudendal  sac,  even  in  dissecting.  In  old 
women  the  sac  flattens  out  and  exposes  the  clitoris  and  nymphse.  The 
clitoris  becomes  smaller  and  blends  with  the  surrounding  parts  so  much  that 
it  is  occasionally  difficult  to  find.  The  vagina  becomes  smoother  in  its  folds. 
It  contracts  in  every  direction  and  frequently  it  may  seem  to  thicken,  but 
that  is  probably  a  delusion  from  blending  with  other  tissue.  The  cervix  gets 
smaller  and  may  appear  entirely  absent,  from  the  excessive  shrinkage  and 
contracting  of  the  vagina.  The  uterus  becomes  smaller  and  harder.  It  has 
a  peculiar  tough,  elastic  feeling  from  the  atrophy  of  muscular  tissue.  It 
assumes  to  some  extent  the  form  it  had  before  puberty,  except  that  the  neck 
is  more  prominent  before  puberty.  It  straightens  out.  Its  nerves  and  ves- 
sels shrink.  The  oviducts  are  notably  thinner  and  shorter.  The  circular 
muscular  layers  seem  to  suffer  most. 

The  ovaries  atrophy  very  much  and  resemble  a  peach-stone  on  the  sur- 
face. In  quite  a  number  of  old  female  cadavers  I  found  them  the  size  of 
beans  and  in  some  it  required  considerable  searching  to  find  and  recognize 
them.  Then  we  found  in  the  contracted  and  atrophic  broad  ligament  the 
sheaths  and  nerves  themselves  atrophied. 

In  Women  with  a  stormy  menopause  it  is  not  unusual  to  find  subinvolu- 
tion. While  a  pupil  of  Lawson  Tait,  fifteen  years  ago,  I  gained  some 
knowledge  in  regard  to  a  disease  of   the   pudendum  which  may  not  infre- 


CLIMACTERIUM  263 

quently  be  seen  in  women  from  forty  to  fifty,  or  about  the  menopause.  It  is 
a  trouble  that  one  would  easily  pronounce  on  a  glance,  eczema  of  the  puden- 
dum. Mr.  Tait  remarked  that  it  was  due  to  a  kind  of  climacteric  diabetes; 
that  is  a  kind  of  eczema  at  the  menopause.  Dr.  Martin,  Mr.  Tait's  assist- 
ant, was  very  kind  in  displaying  to  me  these  unfortunate  cases.  The  labia 
were  swollen  and  edematous  and  the  red  flaming  eczema  extended  far  and 
wide  beyond  the  pudendum.  The  disease  made  the  patient's  life  almost 
intolerable.  Mr.  Tait's  treatment  for  such  cases  was  a  solution  of  hypo- 
phosphite  of  soda  (an  ounce  to  a  pint  of  water).  The  solution  should  be 
applied  every  two  to  five  hours  as  required,  to  destroy  the  germ  which 
induced  the  itching.  He  then  gave  heavy  doses  of  opium.  Mr.  Tait  claims 
that  there  is  a  kind  of  diabetes  mellitis  during  the  menopause;  a  limited 
diabetes,  as  they  all  finally  recover.  The  distress  of  the  patient  with  this 
climacteric  diabetes  is  due  to  the  sugary  urine  causing  irritation  of  the 
pudendum.  Peculiar  crusts  form,  due  to  the  multiplication  of  the  vegetable 
germ  known  as  Torula  cerevisioe.  The  eczema  due  to  this  cause  will  spread 
over  the  buttocks,  over  the  abdomen  and  even  to  the  thighs.  In  one  case  I 
saw  the  eczema  extend  so  far  that  the  patient  could  walk  only  with  difficult}'. 
The  hyposulphite  of  sodium  arrests  the  formation  of  this  germ.  Mr.  Tait 
would  sometimes  give  as  high  as  one  grain  of  opium  three  times  daily  and 
then  two  grains  at  night.  After  a  few  months  of  such  treatment  the  opium 
was  lessened,  and  in  from  five  to  ten  months  such  patients  fairly  recovered. 
They  are  liable  to  mild  relapses. 

M.  Lecorche,  of  Paris,  has  also  made  researches  independently  of  Mr. 
Tait  and  curiously  enough  they  agree  in  many  ways.  Mr.  Tait  carries  his 
views  into  more  definite  plans  of  treatment.  This  climacteric  form  of  diabetes 
is  then  a  disease  which  begins  at  the  menstrual  cessation  and  lasts  a  few 
years.  Menstruation  seems  to  give  immunity  from  it.  Nature  appears  to 
finally  overcome  it.  If  the  hyposulphite  of  sodium  is  inefficient  to  arrest  the 
trouble,  on  account  of  the  fluid  quickly  running  off  the  parts,  an  ointment 
of  sulphur  will  remain  on  the  pudendum  for  hours.  Any  substance  which 
will  arrest  the  fermentation  changes  in  sugar  is  an  effective  remedy.  I  have 
noted  no  special  form  of  climacteric  vaginitis,  but  one  form  is  liable  to  arise 
which  is  due  to  laying  bare  some  peripheral  nerves  in  the  vaginal  wall.  The 
spots  are  red  and  most  exquisitely  tender;  they  occur  mainly  at  the  pudendal 
orifice  and  are  very  persistent.  The  treatment  consists  in  applying  cocaine 
and  sufficient  caustic  or  Paquelin  to  entirely  destroy  the  exposed  nerves. 
These  neuromatic  patches  are  apt  to  arise  in  women  at  other  times  also.  In 
severe  cases  it  is  best  to  anesthetize  the  patient  and  destroy  the  exposed 
nerves  widely  with  the  Paquelin. 

The  special  diseases  of  the  uterus  which  I  have  observed  in  menopause 
are  endometritis  and  myometritis  accompanied  with  leucorrhea.  Chronic 
endometritis  with  an  excoriating  discharge  is  frequently  found.  The  uterus 
is  generally  slightly  large.  The  mouth  is  red,  bleeds  easily  and  out  of  it 
runs  a  muco-purulent  substance  of  varied  color.  The  hot  douche  (15  quarts) 
twice  daily  and  the  additional  use  of   glycerin   tampons  cure   most   cases. 


264  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

Occasionally  a  curetting  is  required,  followed  by  the  thorough  application  of 
95  per  cent,  carbolic  acid.  I  apply  the  95  per  cent,  carbolic  acid  to  the 
endometrium  three  times,  so  that  it  will  destroy  the  old  inflamed  endome- 
trium, and  drain  with  a  little  rubber  tube  or  pack  in  gauze,  and  remove  it  in 
twenty-four  to  thirty-six  hours.  Fortunately  the  senile  endometritis  is  gen- 
erally cured  with  one  curetting,  unlike  the  stubborn  endometritis  of  youth. 
Mild  forms  of  endometritis  in  the  menopause  I  have  frequently  noted. 
The  subinvolution  or  suspended  involution  is  a  much  graver  matter.  It 
has  had  a  more  evil  and  wide  effect  on  health  and  especially  on  the  nervous 
system.  It  consists  essentially  of  a  myometritis,  and  so  far  as  I  can  observe 
rests  on  an  old  endometritis.  It  is  not  clear  whether  Klob  or  Rokitansky 
is  correct,  in  regard  to  the  theories  of  the  conditions  producing  a  hyper- 
trophic uterus. 

Whether  the  hypertrophic  uterus  is  due  to  excess  of  connective  tissue 
or  muscle,  or  whether  it  is  due  to  a  natural  proportionate  increase  of  both  is 

undecided.  In  such  cases  a  lax  pelvic  floor  is  often  observed.  So  far  as 
my  experience  goes,  the  tampons  and  douche  are  insufficient  and  are  too  slow 
for  satisfactory  results.  Thorough  curetting  is  the  best  means  at  command, 
with  the  application  of  95  per  cent,  carbolic  acid  to  the  whole  endometrium. 
The  cure  is  slow  at  best  but  finally  quite  satisfactory.  The  pathology  of  the 
climacteric  or  senile  endometritis  must  not  be  lost  sight  of.  At  first  the 
leucorrhea  is  more  abundant.  It  may  be  mucous,  muco-purulent  and  Anally 
purulent.  The  explanation  of  the  changes  of  the  fluid  secreted  from  the 
endometrium  rests  on  the  endometric  glands.  At  first  the  glands  are  able  to 
be  increased  in  their  function ;  with  time  they  atrophy,  but  the  inflammation 
proceeds  and  finally  only  sero-purulent  substance  or  chiefly  pus  results  from 
the  glandular  destruction;  only  now  and  then  a  glandular  endometritis.  The 
remnants  only  of  the  endometrium  remain  and  these  are  involved  in  a  state 
of  low  vitality.  Low  and  mild  forms  of  granulation  are  visible  at  the  neck 
and  can  be  scraped  out  of  the  uterus.  Slow  necrosis,  local  death,  gradually 
proceeds  until  raw  ulcerative  surfaces  are  exposed  and  only  pus  will  be 
secreted.     The  glands  have  disappeared  practically. 

We  must  observe  that  cervical  laceration  frequently  exists  with  this 
trouble.  The  reason  such  conditions  do  not  heal  well  is  because  the  blood 
supply  and  nerve  supply  to  the  uterus  are  now  being  cut  off,  are  imperfect,  so 
that  nutrition  is  very  deficient  in  the  uterus.  For  thirty  years  the  uterus  has 
had  high  feeding  from  fresh  blood  and  the  fine  control  of  a  complicated  nerve 
apparatus,  but  suddenly  the  high  feeding  is  curtailed  and  the  delicately 
balanced  nerve  apparatus  is  impaired  by  the  atrophy  of  the  menopause. 
Hence  low  granulations,  imperfect  reproductions  of  cells,  ulcerative  surfaces, 
may  be  expected.  It  must  be  remembered  that  there  are  other  troubles 
than  cancer  in  the  uterus  at  the  menopause.  The  essential  feature  of  the 
climacteric  uterine  trouble  is  imperfect  nutrition.  This  will  not  astonish 
one  so  much  after  he  has  carefully  examined  and  dissected  or  post-mortemed 
a  dozen  female  cadavers  above  50  years  of  age.  In  them  he  will  note 
atrophy,  shrinkage,  contraction  and  pale  white  tissue. 


CLIMACTERIUM  t?65 

The  differential  diagnosis  between  cancer  and  benign  uterine  disease 
(endometritis)  may  be  looked  for  in  the  case  of  cancer  by  infiltration,  thicken- 
ing and  peculiar  watery,  sanious  discharges.  As  regards  ovarian  tumors  at 
the  menopause  they  grow  more  rapidly.  The  vital  power  of  the  patient  is  at 
a  lower  ebb,  and  besides  the  nutrition  of  the  ovary  is  degraded  by  dimin- 
shed  blood  supply  and  atrophy  of  its  nerve  supply. 

It  would  appear  that  the  branches  of  the  hypogastric  plexus,  which  are 
sent  to  the  bladder  and  rectum,  are  not  atrophied  to  the  same  degree  as  the 
branches  sent  to  the  genitals  (uterus,  oviducts  and  ovaries).  Yet  in  my 
postmortems  and  dissections  it  appears  to  me  that  the  vesical  and  rectal 
branches  do  atrophy.  The  present  idea  of  medicine  is  that  there  is  an  auto- 
matic structure  disordered  somewhere  to  account  for  disease.  A  portion 
only  of  a  man  is  diseased  and  pathologic  anatomy  would  always  indicate  the 
origin,  had  we  sufficient  acumen. 

Now  in  the  menopause  the  cerebrospinal  axis  is  disturbed  through  the 
means  of  the  vaso-motor  nerves,  and  the  circulation  by  some  form  of  reflex 
neurosis.  A  woman's  mind  is  often  disturbed.  She  has  lost  her  old  will- 
power; her  memory  is  impaired;  she  cannot  concentrate  effort.  She  is  liable 
to  do  damage  from  inability  to  control  her  own  action.  The  law  recognizes 
any  deviation  from  rectitude  during  the  menopause  with  leniency.  The 
treatment  of  women  during  the  menopause  must  be  local,  general  and  moral. 
The  cog  in  the  wheel  which  disturbs  .  even  physical  existence  must  be 
remedied.  General  debility  and  irritability  must  be  allayed  by  anodynes  with 
both  tonics  and  good  nourishment,  while  the  unhinged  moral  views  must  be 
removed  by  changing  the  life  from  the  old  ruts  which  caused  them.  One 
feature  must  not  be  lost  sight  of.  When  pelvic  disease  has  started  a  train 
of  evils  and  continued  for  years,  we  cannot  expect  very  much  from  mere 
treatment,  but  radical  removal  of  diseased  organs  often  alone  gives  relief. 

CONCLUSIONS. 

1.  The  average  menopause  lasts  two  and  one-half  years. 

2.  It  comes  on  slowly  as  does  puberty. 

3.  A  stormy  puberty  means  a  stormy  menopause  generally. 

4.  The  general  rule  is  that  an  early  puberty  means  a  late  menopause. 
In  my  opinion  it  simply  means  that  early  puberty  and  late  menopause  rest  on 
largely  developed  abdominal  and  pelvic  brains  and  hypogastric  plexus. 
Precocious  puberty  means  well  developed  genitals  and  ganglionic  nerves. 

5.  The  disturbance  at  the  beginning  of  puberty  is  profound,  but  since 
it  is  an  active  (depletive)  physiologic  process  it  quickly  fits  the  growing  and 
adaptive  nervous  system.  But  the  menopause  is  a  destructive  process.  It 
breaks  up  the  harmony  of  the  previous  processes  and  unbalances  the  even 
distribution  of  nervous  energy  and  circulation. 

6.  It  is  probable  that  every  viscus  receives  an  equal  or  greater  shock 
at  menopause  than  at  puberty. 

7.  The  changes  at  menopause  consist  in  menstrual  cessation,  atrophy 
of  the  genitals,  the  hypogastric  plexus  and  pelvic  brain. 


266  THE  ABDOMINAL  AXD   PELVIC  BRAIN 

8.  Women  do  not  suffer  at  the  menopause  so  much  from  malignant 
diseases  as  they  do  from  nervous  troubles,  neuralgias,  mental  deviations, 
disturbed  visceral  rhythm,  disordered  circulation,  indigestion  and  above  all 
neuroses. 

9.  The  heat  center  (flashes),  the  vaso-motor  center  (flushes)  and  the 
sweat  center  (perspiration),  are  the  especial  centers  disturbed.  Excessive, 
deficient  or  disproportionate  blood-supply  characterizes  the  disturbed 
phenomena  of  these  centers. 

10.  The  etiology  and  pathology  of  the  menopause  lies  in  the  sympathetic 
or  ganglionic  nervous  system. 

11.  The  sympathetic  pathologic  stages  in  menopause  are:  (a)  a  focus  of 
disease,  or  irritation  (the  genitals),  (b)  indigestion,  (c)  malnutrition,  (d) 
anaemia,  (e)  neurosis.     It  is  a  slowly  progressive  process. 

12.  Atrophy  is  a  disease  just  as  much  as  hypertrophy  or  inflammation. 
Atrophy  traumatises  nerves  by  cicatritial  compression. 

13.  Chief  among  the  actual  disease  in  the  menopause  is  endometritis. 
This  is  due  to  infection  from  desquation  of  epithelia.  The  peculiar  flood- 
ings  doubtless  depend  on  this  inflammation. 

14.  The  menopause  is  characterized  by  various  discharges  (mucous 
membrane),  leucorrhea,  bronchitis,  hemorrhages  from  the  bowels,  epistaxis 
(skin)  perspiration. 

15.  Circulatory,  perspiratory  and  caloric  changes  are  the  common 
heritages  of  the  menopause. 

16.  A  characteristic  phenomenon  of  the  menopause  is  an  unbalanced, 
unstable  nervous  system  ;  cerebrospinal  (irritation),  or  sympathetic  (debility). 

17.  Debility  characterizes  the  trouble  in  the  ganglionic  system,  while 
irritability  characterizes  the  cerebrospinal  axis. 

18.  The  explanation  of  the  various  phenomena  lies  in  the  nervous  and 
circulatory  systems. 

19.  Excessive  sexual  desire  at  the  menopause  is  indicative  of  disease. 

20.  In  the  menopause  the  nutrition  is  impaired,  as  is  shown  by  the 
occurrence  of  malignant  disease  in  the  sexual  organs  which  are  in  a  state  of 
retrogression. 

21.  A  chief  characteristic  of  uterine  disease  is  malnutrition  from 
atrophy,  which  suddenly  limits  blood  supply.  This  arises  from  the  sudden 
degeneration  of  the  genital  nerve  apparatus,  pelvic  brain  and  hypogastric 
plexus,  and  consequent  impaired  control  of  tissue  by  defective  nourishment. 
Ulcerative  processes,  local  death  and  purulent  secretions  arise  from  low 
granular  cell-formations. 

22.  In  the  menopause  a  disturbed  point  has  arisen  in  the  harmony  of 
visceral  rhythm.  This  pathologic  focus  must  be  looked  on  as  the  cause  of 
the  innumerable  reflex  neuroses  at  this  time  of  life. 

23.  A  reflex  neurosis  is  a  disturbance  in  distant  organs  caused  by  the 
irritation  of  a  peripheral  sensory  or  motor  area. 

24.  The  chief  manifestations  of  disturbances  during  menopause  are 
those  of  pathologic  physiology  rather  than  pathologic  anatomy. 


CHAPTER   XXII. 

GENERAL  VISCERAL  NEUROSES. 

The  Peritoneum  holds  in  intimate  connection  the  tractus  intestinalis ,  tractus 
genitalis  and  tractus  urinarius  by  means  of  the  (a)  sympathetic  nerve, 
(b)  blood-vessels,  (c)  lymphatic  vessels,  and  {d)  connective  tissue. 

A  pathological  focus,  a  reflex,  in  any  one  of  the  three  great  abdominal 
visceral  tracts,  produces  disordered  rhythm  or  wild  peristalsis  in  both  of 
the  other  tracts. 

"  The  telegraph  is  the  nervous  sy  stern  of  the  world." — N.  Y.  Herald. 

The  subject  of  visceral  neuroses  must  be  considered  under  three  heads, 
viz. : 

1.  Sensory  Neuroses. — The  state  of  the  sensory  nerves  must  be  con- 
sidered. There  will  be  two  morbid  states  of  the  sensory  nerves  to  consider: 
(a)  pathological  lesions  of  a  more  or  less  demonstrable  sort,  either  in  actual 
changes  in  structure  or  evident  in  reflex  action,  (b)  a  neuralgic  condition, 
a  state  in  which  no  pathologic  lesion  is  demonstrable,  a  kind  of  morbid  or 
exalted  sensibility  or  over  susceptibility  are  those  of  the  sensory  sympathetic 
nerves.  The  neuralgias  and  exalted  sensibility  will  be  discussed  under  the 
hyperesthesias  of  the  abdominal  brain  and  its  radiating  plexuses  of  nerves. 

2.  Motor  neuroses,  the  second  subject,  including  visceral  neurosis,  are 
those  of  motion,  such  as  visceral  rhythm,  motus  peristaltus. 

3.  Secretion  neuroses,  the  third  subject  included  in  visceral  neuroses, 
will  include  the  phenomena  of  secretion,  such  as  excessive,  deficient  or 
disproportionate  secretion. 

VISCERAL  NEUROSES. 

Under  this  head  we  will  include  a  series  of  phenomena  of  the  viscera, 
partly  pathologic  and  partly  reflex,  partaking  of  a  disturbance  of  sensation, 
motion  or  secretion.  By  visceral  neurosis  we  mean  an  undue  irritability 
or  perverted  function  of  one  or  more  of  the  viscera.  The  pathologic  con- 
dition may  be  demonstrable  or  not.     Frequently  it  is  pathologic  physiology. 

In  the  phenomena  of  visceral  neuroses  must  be  included  the  clinical 
fact  that  if  one  organ  is  disturbed  it  will  tend  to  unbalance  the  remainder, 
i.  e.,  irritation  is  reflected  by  a  nerve  arc  from  one  viscus  to  another.  A 
diseased  uterus  is  frequently  followed  by  a  disturbed  stomach.  A  checking 
of  normal  function  not  only  makes  neurosis  but  indigestion,  non-assimilation 
and  anemia.  Such  a  case  occurred  in  the  person  of  a  young  woman  on  whom 
I  performed  laparotomy.  A  few  months  after  the  operation  she  began  to 
suffer  tenesmus,  spasmodic  dragging  pain  in  the  sacrum  at  defecation,  and 
colica  membranacea  arose.  She  became  slowly  ill,  neurotic  and  unable  to 
work.     Dr.  Lucy  Waite  and  I  operated  on  her  and  all  that  we  found  was  an 

267 


268  THE  ABDOMIXAL  AND  PELVIC  BRAIN 

organized  peritoneal  band  several  inches  long  stretching  from  the  amputated 
oviductal  stump  to  the  middle  of  the  sigmoid.  The  peritoneal  band  checked 
the  normal  peristaltic  action  of  the  sigmoid,  producing  pain,  non-assimilation, 
anemia  and  indigestion.  She  became  well  after  the  operation,  gaining  some 
twenty  pounds.  In  over  a  dozen  cases  during  the  past  three  years  Dr.  Lucy 
Waite  and  I  have  reoperated  for  old  post-operative  peritoneal  adhesions. 
We  generally  found  that  some  loop  of  bowel  was  attached  to  the  amputated 
end  of  the  oviduct  and  checked  more  or  less  the  bowel  peristalsis.  Hence, 
partial  checking  or  hindering  of  bowel  peristalsis  produces  a  peculiar  kind  of 
neurosis.  All  one  may  notice  at  first  in  such  cases  is  irritability.  Pain  may 
not  be  spoken  of  as  the  chief  annoyance.  These  subjects  with  peritoneal 
bands,  which  more  or  less  interfere  with  visceral  rhythm  and  peristalsis 
suffer  in  distant  organs  from  reflex  irritation  radiating  to  them.  It  should 
be  remembered  that  reflex  action  goes  on  in  health  and  disease.  Nerves 
like  railway  cars  carry  any  kind  of  freight. 

The  essentials  of  a  nervous  system  consist  of  (a)  a  central  nerve  cell,  (b) 
a  conducting  cord,  and  (c)  a  peripheral  apparatus.  However  vast  the 
nervous  system,  the  elements  are  the  same.  For  example,  the  skin  is  the 
peripheral  apparatus,  the  spinal  nerves  are  conducting  cords  and  the  spinal 
cord  the  central  nerve  cells.  The  same  form  of  illustration  may  be  made  in 
regard  to  the  abdominal  and  pelvic  brain  as  in  the  central  nerve  cell.  The 
superior  and  inferior  mesenteric  plexuses  of  nerves  are  the  conducting  cords 
(for  the  intestines)  and  the  peripheral  apparatus  is  in  the  mucosa.  In 
visceral  neuroses  pain  is  not  always  the  chief  symptom.  Subconscious 
irritation  plays  the  chief  role;  irritation  which  does  not  come  within  the 
field  of  recognized  pain. 

Among  visceral  neuroses  we  should  include  enteroptosia.  The  maladie 
dc  Glenard  is  doubtless  a  neurotic  disease  belonging  to  the  domain  of  the 
nervous  vasomotorius.  Recently  Dr.  Schwerdt  has  written  some  interesting 
and  well  studied  articles  on  enteroptosia.  Visceral  neurosis  means  that  the 
nervous  system  in  the  abdomen  and  the  organs  are  not  living  in  harmony. 
The  gamut  of  the  sympathetic  nerve  has  lost  its  tone. 

Enteroptosia  begins  in  respiration  and  from  a  weakness  of  the  abdominal 
sympathetic,  which  became  tired  and  slacken  in  its  tone.  The  sympathetic 
nerves  to  the  viscera  have  lost  their  normal  power  over  circulation,  assimila- 
tion, secretion  and  rhythm;  but  the  sympathetic  nerves  have  lost  their 
influence  over  the  viscera  very  slowly,  for  the  enteroptosia  is  a  very  slow 
disease  at  first  and  has  a  long  chronic  course  from  the  beginning.  It  may 
require  years  to  develop.  In  a  later  stage  of  enteroptosia  the  disturbance 
of  feeling  and  motion  arises,  and  the  nervous  symptoms  of  disturbed  diges- 
tion, aortic  palpitation  and  dragging  sensation.  Later  the  disturbance  of 
motion  occurs.  The  abdominal  walls  slacken,  lose  their  tone  and  atrophy 
even  the  extremities  losing  some  of  their  delicate  balance.  But  with  the 
lowering  of  the  intra-abdominal  pressure  the  real  ptosia  of  the  viscera  begins 
and  the  neurosis  rapidly  increases.  The  anatomical  visceral  pedicles  elongate, 
the  organs  begin  to  leave  their  bed. 


GENERAL   VISCERAL  NEUROSES. 


869 


SYMPATHETIC  NERVE  IN  LUMBAR  REGION 

119  f1fg,6V  1I4'  ga,n§!ia  at  ?rigin  of  inferior  mesenteric  artery;  115,  interiliac  nerve  disc: 
114  lateral  sympathetic  chain  ;  156,  rectum  ;  181,  common  iliacs. 


270  THE  ABDOMINAL  AND  PELVIC  BRAIN 

The  digestive  tract  being  disturbed,  the  nervous  system  suffers  from 
auto-intoxication.  Assimilation  becoming  deranged  by  a  continuously  dis- 
turbed digestive  tract,  a  vicious  circle  begins  its  progress.  The  motor, 
sensory  and  secretory  nerve  apparatus,  each  and  all,  become  involved. 
Anatomically,  we  observe  the  order  of  visceral  ptosia  (I  base  this  on  some 
seven  hundred  personal  autopsies)  to  be  the  following:  1,  the  right  kidney; 
2,  the  stomach;  3,  the  small  intestines;  4,  the  transverse  colon;  5,  the 
spleen ;  6,  the  liver,  and  7,  the  genitals.  Visceral  ptosia  belongs  in  the  vast 
majority  of  living  diagnoses  to  women,  but  autopsies  show  the  disease  quite 
common   in  women  and  not  rare  in  men. 

The  slackening  and  atrophy  of  the  female  abdominal  wall  makes  the 
diagnosis  easy,  while  the  retention  of  tone  in  the  abdominal  wall  of  men  not 
only  makes  visceral  ptosia  rare  in  men  but  more  difficult  to  diagnose.  The 
typical  enteroptosia  occurs  in  old  age  when  the  sympathetic  has  lost  its  tone 
and  vigor.  In  a  normal  condition  of  the  abdominal  viscera  the  several  organs 
hold  a, harmonious  relation  to  each  other,  no  nerve  plexus  is  stretched  or 
slackened,  and  function,  secretion,  assimilation,  circulation  and  rhythm  move 
without  friction.  Now,  with  dislocated  organs  dragging  irregularly  on  the 
nerve  plexuses,  deranging  secretion  and  assimilation,  the  suffering  becomes 
manifest  in  what  we  know  as  visceral  neurosis.  Some  designate  it  hysteria. 
The  lost  tone  and  vigor  of  the  anterior  abdominal  wall  is  unfortunate  because 
its  vigorous  aid  to  peristalsis  is  wanting.  The  loss  of  the  muscular  action 
of  the  anterior  abdominal  wall  allows  congestion  of  blood  and  secretions  to 
arise;  and  constipation  intervenes. 

In  visceral  ptosis  the  skin  presents  anesthesia  and  hyperesthesia,  also 
vicarious  actions  to  elemental  products.  In  enteroptosia  we  have  various 
functional  paralyses.  The  physical  and  mental  vigor  is  paretic  in  entero- 
ptosia. It  produces  languor.  The  intestinal  tract  is  sluggish,  paretic.  The 
bowel  suffers  in  two  ways,  first,  from  auto-intoxication;  second,  from  the 
irritation  of  the  decomposing  material  on  its  mucosa,  which  reacts  on  the 
nervous  system.  The  disturbed  skin  trouble  in  enteroptosia  points  to  hydro- 
therapy as  the  best  way  out.  Baths  open  the  drains  of  the  skin.  Entero- 
ptosia is  a  functional  disease. 

In  enteroptosia  as  a  visceral  neurosis  we  deal  with  several  stages,  each  of 
which  presents  distinct  landmarks. 

In  the  first  stage  we  deal  with  increasing  muscular  weakness.  The 
pati.ent  complains  of  manifold  sensations  on  account  of  disturbances  in  the 
sympathetic,  anemia,  defective  assimilation  and  loss  of  weight.  Physical 
and  mental  energy  become  lowered  and  intra-abdominal  pressure  becomes 
lessened.     The  disease  may  not  extend  further. 

In  the  second  stage  of  enteroptosia  the  name  of  the  disease  is  quite  apt, 
for  the  individual  viscera  begin  to  leave  their  old,  natural  beds.  They 
become  dislocated,  and  permanently  fixed  in  wrong  positions.  (However, 
by  force  or  the  patient  assuming  an  unnatural  position  the  dislocated  viscera 
may  resume  their  proper  position.)  With  the  dislocated  organs  begin  the 
visceral  neuroses,  the  indigestion   and  the  auto-intoxication.       In  this   stage 


GENERAL  VISCERAL  NEUROSES  271 

the  abdominal  brain  and  its  radiating  plexuses,  as  well  as  the  vessels  sur- 
rounded, must  become  adjusted  to  the  new  environments  of  drawing  and 
pressure;  compensations  of  atrophy  and  hypertrophy  will  arise.  For 
example,  the  power  of  the  muscular  wall  of  the  abdomen  being  lessened,  the 
digestive  tract  must  compensate  by  increasing  its  muscular  wall  in  order  to 
drive  onward  the  fecal  mass. 

The  third,  and  final,  stage  of  enteroptosia  may  be  observed  in  some  old 
people.  It  is  the  stage  in  which  compensatory  hypertrophy  fails;  and  the  vis- 
cera becoming  overfilled,  depletion  is  very  imperfect.  The  digestive  tract  is 
unable  to  empty  itself  from  the  remnants  of  its  feasts,  and  excessive  venous 
congestions  arise,  the  bladder  is  able  to  expel  but  a  little  urine  at  a  time 
and  the  digestive  tract  suffers  from  the  absorption  of  toxins  and  the  irrita- 
tion from  decomposing  material. 

In  one  case  of  enteroptosia,  postmortemed  by  Dr.  Lucy  Waite  and 
myself,  the  greater  curve  of  the  stomach  rested  on  the  pelvic  floor.  The 
subject  was  an  old  man.  In  another  case  in  which  I  performed  the  autopsy 
the  spleen  was  resting  on  the  pelvic  floor.  It  is  common  in  autopsies  to  find 
the  right  kidney  movable  for  two  inches  proximalward  and  two  inches 
distalward — a  range  of  four  inches.  The  transverse  colon  is  frequently 
found  in  the  pelvic  cavity. 

The  treatment  of  enteroptosia  may  be  summed  up  in  the  words,  hydro- 
therapy and  abdominal  support.  The  young  surgeon  who  performs  nephror- 
rhaphy  for  movable  kidney  will  have  his  hands  full,  if  he  has  a  large  practice, 
for  I  know  from  personal  experience  in  autopsy  and  practice  in  gynecology 
and  abdominal  surgery,  that  movable  kidney  is  a  very  frequent  occurrence. 
I  should  judge  that  five  women  out  of  ten,  who  come  to  my  office,  have  a 
movable  right  kidney.  Movable  kidney  is  a  part  of  enteroptosia — nephro- 
ptosia.  Now,  since  patients  afflicted  with  enteroptosia  surfer  from  auto- 
intoxication, non-elimination,  non-drainage  and  congestion,  we  must  aid 
Nature  by  establishing  general  drainage.  Frequent  salt  baths,  persistent 
massage  and  abdominal  supporters  are  required  in  the  treatment.  Above 
all,  the  digestive  tract  must  be  frequently  evacuated  once  daily  by  adminis- 
tering a  full  glass  of  water  with  half  a  dram  of  epsom  salts  and  ten  drops  of 
tr.  nux  vomica  every  night  on  retiring,  and  insist  on  the  patient  emptying  the 
bowels  regularly  every  morning  at  the  same  hour.  The  abdominal  bandage 
should  be  of  elastic  flannel  and  fit  snugly.  It  may  be  removed  at  night. 
The  abdominal  binder  affords  much  comfort.  In  fact,  one  of  the  methods  of 
diagnosing  enteroptosia  is  to  elevate  the  viscera  and  then  to  note  whether 
the  pain  ceases. 

It  may  not  be  forgotten  that  enteroptosia  offers  opportunities  not  only 
for  visceral  neuroses,  but  also  for  obstinate  constipation,  which  favors  the 
development  of  visceral  neuroses  by  over-retention  of  feces,  including  decom- 
position of  matter,  calling  up  irritation  and  auto-intoxication.  Each  factor 
in  enteroptosia  induces  a  vicious  circle.  The  factors  in  enteroptosia  which 
solicit  constipation  are: 

1.     Flexing  of  the  colon  by  the  ligamentum  hepato-colicura. 


272  THE  ABDOMINAL   AXD   PELVIC   BRAIN 

2.  Flexing  of  the  colon  by  the  ligamentum  phrenico-colicum  sinistrum. 

3.  Flexing  of  the  right  colon  by  the  ligamentum  phrenico-colicum 
dextrum.     I  have  seen  the  right  colon  in  the  pelvis  hanging  by  this  band. 

4.  Flexing  of  the  pylorus  by  the  ligamentum  hepato-duodenum. 

5.  Atony  of  the  gastro-intestinal  muscularis. 

6.  A  lowering  of  the  intra-abdominal  pressure  by  atony  of  the  anterior 
abdominal  muscles. 

7.  The  excessively  mobile  viscera  with  elongated  pedicles  locally  com- 
promise the  bowel  lumen  as  well  as  that  of  vessels. 

In  sensory  visceral  neurosis  (or  neuralgia)  we  are  doubtless  dealing  with 
a  peculiar  form  of  malnutrition  of  the  nerves  of  sensation.  Hence  in  these 
days  of  scalpel  or  no  scalpel,  of  sweeping  removal  or  surgical  repair,  it 
behooves  us  to  diagnose  with  caution  the  symptoms  of  disease.  In  disease  we 
are  seldom  dealing  only  with  signs,  which  are  distinct  clews  to  disease,  but 
chiefly  with  symptoms  which  are  only  indications  of  pathology.  In  visceral 
(abdominal)  neuroses  we  are  dealing  with  organs  which  possess  (a)  motion, 
(b)  sensation  and  (c)  secretion;  i.  e.,  such  organs  have  muscles  which  are 
set  in  motion  by  motor  nerves,  sensation  made  manifest  by  some  irritation 
on  the  sensory  nerve  ends,  and  secretion  which  proceeds  normally  in  certain 
quantities,  but  in  disturbed  conditions,  (a)  excessive,  (b)  deficient,  or  (c) 
disproportionate. 

In  visceral  (abdominal  and  thoracic)  neuroses  we  are  chiefly  dealing  with 
the  vasomotor  (sympathetic) — a  nerve  of  rhythmical  motion  and  dull  sensa- 
tion. The  term  visceral  (abdominal  and  thoracic)  neurosis  is  a  mere  name 
of  a  symptom  in  the  minds  of  many  physicians,  as  we  say  the  kettle  boils 
when  we  really  mean  that  the  water  boils  or  is  raised  to  such  a  degree  of 
temperature  that  the  ebullition  occurs  in  the  water. 

Visceral  neurosis  indicates  that  some  deep  condition,  assimilation  or 
vicious  process  is  proceeding  somewhere.  The  observing  physician  of 
experience  commonly  associates  in  his  mind  visceral  neuroses  with  (a)  some 
debilitating  process  in  age  or  sex.  We  cast  about  for  predisposing  causes 
and  examine  them  as  a  neurotic  temperament,  hereditary  or  acquired.  One 
can  acquire  a  neurotic  disposition  by  dissipation,  sexual  or  with  narcotics, 
by  excessive  and  prolonged  labor,  the  absorption  of  poisonous  substances,  as 
lead,  arsenic  or  phosphorus.  Rapid  changes  of  temperature  bring  on  visceral 
disturbances,  (b)  We  also  take  into  account  sex.  It  is  difficult  to  say  which 
sex  suffers  the  most  from  visceral  (abdominal)  neuroses.  I  should  judge 
women  do.  But  different  varieties  of  visceral  neuroses  prevail  in  each  sex, 
and  at  different  periods  of  life. 

(c)  The  chief  age  of  visceral  neuroses  is  from  twenty  to  sixty.  Few 
cases  occur  before  twenty  and  rarely  after  sixty.  (d)  The  sexual  life  of 
woman  is  rich  in  visceral  (abdominal)  neuroses  at  different  periods  as-(l)  at 
puberty,  (2)  at  the  menopause,  (3)  at  the  menstrual  period,  (4)  daring  preg- 
nancy, (5)  in  the  puerperium,  (6)  there  are  neuroses  from  excess  of  abstin- 
ence from  venery.  In  the  above  six  factors  the  circulation  plays  an 
important  role.     In  short,  the  neurosis  is  secondary  to  some  other  process. 


GENERAL   VISCERAL  NEURO 


373 


(e)  Visceral  (abdominal)  neuroses  are  commonly  associated  with  genital 
malnutrition,  as  in  anemia,  cachexia  from  malignant  disease,  chlorosis, 
debility,  mental  or  physical,  from  irritation,  reflex  action,  over-strain. 
Diabetic,  gouty  and  rheumatic  persons  suffer  from  visceral  neuroses.  In  the 
above  factors  reflex  irritation  plays  the  chief  role. 

(f)  In  the  etiology  of  visceral  neuroses  we  must  include  all  kinds  of 
trauma  to  nerves,  contraction  of  cicatricial  tissue,  pressure  of  adjacent 
organs,  tumors  and  pressure  on  nerves,  adjacent  inflammatory  tissue,    dis- 


SACRAL  SYMPATHETIC  AND  SACROSPINAL   NERVES 

Fig.  62.  This  illustration  is  drawn  from  a  woman  about  40  years  of  age. 
It  represents  the  sacral  sympathetic  and  sacro-spinal  nerves  Is,  2s,  3s,  4s  and 
os,  sacral  ganglia.  Sc.  N.  sciatic  nerve.  The  sacral  sympathetic  ganglia  are 
connected,  anastomosed  by  transverse  strands. 

located  organs  dragging  as  in  visceral  ptosia;  in  short,  trauma,  pressure  and 
dragging. 

(g)  Many  visceral  neuroses  rest  on  infection  or  intoxication,  as  malaria, 
typhoid  fever,  or  poisoning  with  lead,  copper,  mercury  and  other  agents. 

(h)  Catching  cold,  rapid  changes  of  temperature,  cold  and  wet  weather, 
play  a  role  in  the  etiology  of  visceral  neuroses. 

(i)  Visceral  neuroses  may  depend  on  (1)  a  small  abdominal  brain,  (2) 
deficient  blood  supply,  (3)  continued  disease,  (-i)  premature  senility,  (5) 
temporary  invagination  of  the  bowels. 


274  THE  ABDOMIXAL   AX  D   PELVIC  BRAIX 

(j)  A  peculiar  affection  of  the  rectum  of  a  neuralgic  character  sometimes 
arises.  It  occurs  in  robust  as  well  as  neurotic  persons.  The  patient  will  go 
to  bed  well  and  wake  up  at  any  hour  of  the  night,  with  a  severe  pain  in  the 
rectum,  about  the  large  prostatic  plexuses  of  man  and  about  the  cervico- 
uterine  ganglia  of  woman.  I  know  one  patient  who  has  had  such  an  affection 
for  over  ten  years.  The  pain  rises  to  a  maximum  and  remains  intense, 
gnawing  and  grinding  for  from  ten  minutes  to  nearly  an  hour,  when  it  will 
suddenly  pass  away.  No  cause  can  be  assigned  in  this  case,  for  the  patient 
lives  in  apparently  perfect  health. 

The  symptom,  par  excellence,  of  visceral  neuroses,  is  pain.  The 
patients  describe  the  pain  in  manifold  ways  as  boring,  dragging,  burning, 
stabbing,  pressing,  lancinating,  grinding  and  tearing.  Usually  the  pain  is 
paroxysmal,  ceasing  in  the  intervals.  The  pain  on  lessening  may  be  very 
irregular,  slight  or  intense. 

Upon  one  point  concerning  neuralgia  (visceral  or  otherwise)  I  am  doubt- 
ful, and  that  is  that  the  nerves  have  distinct  local  points  of  tenderness: — Dr. 
Yalleix's  announcement,  for  example,  of  the  three  tender  points  on  the  inter- 
costal nerves.  But  by  careful  examination  and  an  opportunity  to  compress 
the  nerves,  we  would  likely  elicit  pain  in  any  or  all  points  of  a  neuralgic 
nerve.  The  patient  can  scarcely  give  distinct  localities  of  tenderness,  for 
mechanical  pressure  elicits  distinct  pain.  The  irregularity  of  the  various 
localities  of  pain  in  visceral  neuralgia  shows  that  it  is  not  a  mere  local  dis- 
order but  some  germinal  malnutrition  of  the  sensory  apparatus.  Visceral 
neuralgia  not  only  occurs  in  the  trunks  but  along  the  branches  of  nerves,  as 
some  patients  will  complain  of  pain  in  various  regions  of  the  hypogastric 
trunks,  but  of  irregular  pain  in  the  spermatic  branches  or  in  the  testicle. 
During  the  attacks  of  visceral  neuralgia  various  accompanying  secondary 
affections  arise,  as  vasomotor  disturbances,  muscular  disturbances.  The 
vessels  contract,  lessening  the  amount  of  blood  passing  through  them,  and 
muscular  action  brings  contractions  (colic)  in  local  and  remote  regions  of  the 
abdomen ;  shifting,  colicky  cramping  pains  characterize  the  visceral  neural- 
gias. In  one  patient  on  whom  we  operated  the  second  time,  complaining  of 
varying  pains  in  the  right  side,  we  found  the  liver  and  stomach  prolapsed 
considerably.  Since  the  operations  she  complains  of  irregular  pains  still  in 
the  right  side  where  we  made  no  interference.  We  do  not  operate  for  pain 
in  the  right  side,  but  for  other  reasons,  yet  we  noted  much  visceral  ptosia  of 
the  stomach  and  liver  in  the  region  of  these  neuralgic  pains.  In  many  cases 
I  have  noted  the  evil  effects  of  peritoneal  adhesions  previous  and  subsequent 
to  abdominal  section,  and  Dr.  Lucy  Waite  and  I  have  operated  on  many 
patients  a  second  time  for  the  pain  caused  by  peritoneal  adhesions,  fixing 
movable  viscera  and  interfering  with  their  function,  rhythm  and  peristalsis. 
Peritoneal  adhesions  produce  as  symptoms  a  kind  of  visceral  neurosis,  how- 
ever; the  pain  of  peritoneal  adhesions  is  certainly  more  constant,  in  the 
language  of  the  patient,  as  dragging  sensation  repeating  itself  on  prolonged 
efforts. 

Peritoneal    adhesions,   will,   no  doubt,   explain  man}'  cases   of    visceral 


GENER.  I L   I  'ISC  E  A'.  I L  NE  L  rROSES  r, 5 

neuralgia.  In  numerous  abdominal  autopsies  T  found  practically  the  follow- 
ing percentage  of  peritoneal  adhesions  in  the  following  locations,  viz.— (1) 
At  the  proximal  ends  of  the  oviducts,  80  percent  in  adults;  (2)  in  the  mes- 
osigmoid  over  the  left  psoas,  80  per  cent  in  adults;  (3)  in  the  ileo-coeco — 
appendicular  apparatus  on  the  right  psoas,  To  per  cent ;  (4)  in  the  gall-bladder 
region  45  per  cent;  (5)  00  per  cent  occurs  adjacent  to  the  spleen.  Also 
numerous  peritoneal  adhesions  occur  at  the  flexures  of  the  tractus  intesti- 
nalis,  viz.  —  (a)  Flexura  coli  lienalis;  (b)  flexura  coli  hepatica;  (c)  flexura 
duodeno-jejunalis.     Peritoneal  adhesions  compromise  the  circulation  (blood 


91  -l-^i  :t     /■■  7 


CERVICAL  GANGLIA 

Fig.  63.  6,  superior;  7,  middle  cervical  sympathetic  ganglia;  9,  1",  11,  12,  13, 
cervical  nerves  (spinal)  ;  24,  25,  26,  27,  cervical  rami  communicantes ;  3,  vagus; 
20,  superior  cardiac  from  superior  cervical;  2,   hypoglossel. 

and  lymph)  peristalsis,  absorption  and  secretion  of   viscera,  as  well  as  trau- 
matises  (neuralgia)  the  visceral  nerves. 

Another  patient  complained  of  a  varying  pain  along  the  left  ovarian 
plexus,  and  again  for  months  in.  the  region  of  the  left  kidney.  Physically, 
nothing  could  be  discovered  except  that  she  was  very  anemic.  I  am  thor- 
oughly convinced  that  considerable  visceral  pain  arises  from  pressure  of  fecal 
masses  as  they  pass  over  the  nerve  plexuses,  also  that  the  hard,  irritating 
fecal  masses  stir  up  local  bowel  contractions  (colic)  as  they  move  toward  the 
rectum.     This  accounts  for  the  clinical  fact  that  the  visceral  neuralgic  pains 


276  THE  ABDOMIXAL   AXD   PELVIC  BRAIN 

fast  disappear  when  cathartics  are  so  used  as  to  regulate  a  daily  stool.  In 
my  practice  of  gynecology  nothing  has  produced  better  results  in  constipation 
than  the  drinking  of  a  full  glass  of  water,  with  one-quarter  teaspoonful  of 
epsom  salts  on  retiring,  and  going  to  stool  promptly  after  breakfast  every 
morning.  The  more  I  practice  gynecology  and  abdominal  surgery  the  more 
I  become  acquainted  with  visceral  ptosis  and  its  evil  results,  and  the  more 
I  am  convinced  that  visceral  neuralgia  has  a  physical  basis  whose  pathology 
will  become  more  manifest  with  study. 

It  is  difficult  to  point  out,  precisely,  the  symptoms  of  visceral  neuralgia, 
for  the  very  simple  fact  that  we  do  not  yet  know  the  definite  functions  of 
the  visceral  nerves.  We  must  compare  the  visceral  neuralgia  with  the  better 
known  neuralgia  of  the  trigeminus.  It  has  been  stated  that  neuralgia  is  a 
prayer  of  the  nerve  for  nourishment  or  for  fresh  blood.  We  often  notice 
that  a  nerve  subject  to  neuralgia  is  sensitive  to  pressure.  So  in  our  diagnosis 
we  must  follow  the  track  of  sensitive  nerves  in  the  abdomen.  To  do  this  we 
must  know  that  there  are  great  bundles  or  trunks  of  nerves  called  plexuses 
which  quite  generally  follow  large  blood-vessels.  Great  ganglia  exist  in 
different  localities  of  the  abdomen,  which  space  forbids  even  naming.  In 
short,  we  have  to  deal  with  the  abdominal  brain,  the  inferior  mesenteric  gan- 
glion, the  cervico-uterine  ganglia  and  the  lateral  chain  of  ganglia  and  hosts 
of  smaller  ones,  all  connected  by  nerve  cords.  The  sympathetic  nervous 
system  which  supplies  the  abdominal  viscera  is  partly  independent  of  the 
remainder  of  the  nervous  system  and  partly  intimately  connected  with  its 
ganglia  by  fibers  from  the  brain  and  cord.  The  ganglion  fibers  are  the  greater 
part  motor  and  innervate  the  involuntary  muscles  of  the  viscera.  We  deal 
with  the  nervous  system  of  the  abdomen  as  composed  of  the  (a)  lateral  chain 
of  ganglia,  (b)  the  abdominal  and  pelvic  splanchnics,  (c)  the  rami  commun- 
icantes,  (d)  the  vagi  nerves,  and  (e)  the  abdominal  brain  with  all  the  nerve 
ganglia.  We  have  but  space  to  mention  the  special  forms  of  neuralgia  which 
have  been  attached  to  different  abdominal  organs  under  the  general  term  of 
visceral  neuralgia.  Some  of  the  following  forms  of  visceral  neuralgia  have 
gained  a  place  in  medical  literature: 

1.  Hepatic  neuralgia,  or  colica  hepatica  non-calculosa. 

2.  Neuralgia  of  the  stomach,  or  gastralgia. 

3.  Enteralgia  (colica  mucosa  Nothnagel;  or  better,  secretion  neurosis 
of  the  colon). 

4.  Ovarian  neuralgia. 

5.  Neuralgia  rectalis. 

6.  Neuralgia  renalis. 

7.  Oviductal  colic. 

8.  Uterine  neuralgia. 

Hepatic  neuralgia  rests  on  the  view  that  pain  of  a  neuralgic  character 
arises  in  the  liver  region  when  gall-stones  do  not  appear  in  the  stool  nor  are 
found  in  the  autopsy.  Andral,  Budd,  Frerichs,  Furbinger,  Durand,  Bardel  and 
Schiippel  are  names  representing  belief  of  hepatic  neuralgia  with  no  calculus 
as  a  cause.     Gastralgia  has  been  so  long  in  medical  literature  that  it  need 


GENERAL  VISCERAL  NEUROSES  277 

not  be  supported  by  any  names.  Enteralgia  in  its  various  indefinite  forms 
is  seen  by  gynecologic  practitioners  frequently. 

With  more  accurate  study  the  biliary  neuralgias  will  disappear  and  be 
replaced  by  more  accurate  terms  as  cholecystitis,  choledochitis,  etc.,  in  short 
violent  spasm  or  colic  of  some  segment  of  the  biliary  ducts  is  due  to  inflamma- 
tion or  calculus.  During  700  personal  autopsic  inspections  of  the  abdominal 
viscera  I  demonstrated  that  some  45  per  cent  of  peritoneal  exudates,  adhe- 
sions existed  adjacent  to  the  gall-bladder  and  other  biliary  passages.  Dr. 
Robert  Morris,  of  New  York,  christened  these  subjects  spider  gall-bladder 
adhesions.  The  peritoneal  adhesions  adjacent  to  the  gall-bladder,  will,  no 
doubt,  explain  much  hepatic  neuralgia  of  the  older  doctors  as  well  as  gastric 
neuralgia  or  gastralgia. 

Ovarian  neuralgia  is  a  disease  glibly  talked  about,  but  very  difficult  to 
diagnose.  I  have  listened  perhaps  hundreds  of  times  to  descriptions  of 
patients'  suffering  which  some  would  designate  ovarian  neuralgia.  Yet 
women  do  have  irregular  pain,  slight  and  intense,  in  the  ovary.  The  ovary 
will  be  found  sensitive  and  painful  on  pressure.  It  is  the  opinion  of  the 
writer  that  so-called  ovarian  neuralgia  is  a  secondary  process,  and  yet  it 
doubtless  exists,  as  certain  as  neuralgia  of  the  upper  division  of  the  trig- 
eminus. Neuralgia  of  the  rectum  has  a  definite  existence.  It  comes  and 
goes  with  great  irregularity,  arising  chiefly  at  night  and  appears  in  persons  of 
apparently  robust  health. 

Neuralgia  of  the  kidney  rests  on  the  fact  that  pain  occurs  in  the  region 
of  the  kidney;  the  kidney  is  sensitive  to  pressure,  and  no  stone  has  been 
found  in  the  kidney  at  the  autopsy.  The  pain  has  been  so  severe  that  neph- 
rectomy was  performed,  but  the  kidney  contained  no  stone.  In  one  patient 
who  had  pain  and  tenderness  in  the  region  of  the  kidney  for  three  years  I 
performed  the  operation  of  incising  the  kidney.  No  stone  was  found,  but  an 
old  scar  existed  in  the  kidney  pelvis,  and  also  opposite  to  the  scar  in  the 
kidney  there  existed  a  mass  of  old  cicatricial  tissue  as  large  as  a  plum.  The 
conclusion  was  that  a  stone  had  once  ulcerated  through  the  pelvis  of  the  kid- 
ney and  that  she  was  suffering  from  the  cicatrix  in  and  about  the  kidney. 

Oviductal  and  uterine  colic,  or  so-called  neuralgia,  rests  on  the  peculiar 
structure  of  the  oviducts  and  uterus.  Their  involuntary  muscular  walls,  being 
supplied  by  sympathetic  nerves,  are  liable  to  be  set  in  motion  by  various 
forms  of  irritation,  and  hence  from  tonic  and  clonic  spasms  of  their  walls  are 
liable  to  give  rise  to  irregular  flying  pains  or  visceral  neuralgia. 


CHAPTER  XXIII. 

RELATION  BETWEEN  VISCERAL  (SYMPATHETIC)  AND 
CEREBRO-SPINAL  NERVES. 

"I  have  observed  matters  contained  in  this  book,  a  large  part -of  which  is  myself." 
"I  exist,  therefore,  I  am." — Kant. 

THE   NERVE  MECHANISM  OF  PELVIC  AND  ASSOCIATED  REGIONS. 

The  plan  of  the  nerve  supply  of  the  pelvis  and  associated  regions  is  to 
bring  into  harmonious  action  the  skin  and  mucosa  and  the  muscles  and 
viscera.  The  object  of  the  generative  organs  is  not  only  gestation  and 
expulsion  but  also  for  the  varied  necessity  of  copulation,  of  defecation,  and 
of  urination,  including  muscular  and  visceral  relations. 

The  nerve  mechanism  of  the  external  genitals  is  significant  and  suggest- 
ive of  an  evolutionary  plan.  The  sympathetic  nerves  extensively  supply  the 
erectile  tissues — the  corpora  cavernosa,  glans  clitoridis,  and  bulbi  vaginae. 
The  erectile  tissues  possess  rhythmical  action,  besides  being  supplied  with 
nerves  from  the  lumbar  plexus  (genito-crural)  and  the  sacral  plexus  (pudendal 
and  internal  pudic).  The  internal  pudic  nerve  (sacral  plexus),  which  chiefly 
supplies  the  clitoris  with  large  branches,  terminates  in  the  glans  clitoridis  or 
adjacent  tissue  in  peculiar  tactile  or  genital  corpuscles.  The  clitoris  and 
considerable  of  the  adjacent  region  of  the  distal  third  of  the  vagina  is  exceed- 
ingly sensitive  to  irritation. 

The  plan  of  the  nervous  mechanism  of  the  external  genitals  is  to  associ- 
ate the  genitals  with  certain  muscles  and  overlying  skin.  The  nerves  which 
supply  the  pelvis  and  associated  viscera  are:  1.  The  sympathetic,  the  hypo- 
gastric plexus  and  ovarian  plexus,  both  arising  from  the  abdominal  brain : 
also  branches  of  the  lateral  chain  of  the  sympathetic.  The  pelvic  viscera 
thus  involve  nerve  relations  with  all  the  other  abdominal  viscera.  2.  The 
cerebro-spinal  nerve  supply,  the  lumbar  plexus  furnishes  the  genito-crural, 
the  ilio-hypogastric,  and  the  ilio-inguinal  and  inferior  pudendal ;  also  the 
sacral  plexus  supplying  the  internal  pudic  and  vesical.  The  cerebro-spinal 
nerves  supplying  the  skin  and  muscle  associate  them  with  the  genitals.  The 
skin  on  the  pudendum,  perineum,  and  anal  region  is  definitely  associated 
with  the  skin  in  the  inguinal  region,  the  inner  part  of  the  thigh  and  genital 
region,  because  branches  from  the  lumbar  and  sacral  nerve  trunks  supply 
the  same  regions.  For  example,  the  genito-crural  nerve  supplies  the  skin 
on  the  pudendum  and  the  ilio-inguinal  supplies  the  skin  over  the  gluteal 
muscles.  The  genito-crural  and  ilio-inguinal  are  both  branches  of  the 
lumbar  plexus  and  what  affects  the  pudendal  skin  will  affect  the  gluteal  skin. 
Besides  the  same  nerve  trunk  that  sends  branches  to  the  skin  also  sends 

278 


RELATION    OF    CEREBROSPINAL    TO    SYMPATHETIC      ■_<::> 

branches  to  the  underlying  muscle.  Also  the  internal  pudic,  a  branch  of  the 
sacral  plexus,  supplies  the  skin  on  the  pudendum,  perineal,  and  anal  region, 
while  the  small  sciatic,  a  branch  from  the  same  plexus,  supplies  the  skin  on 
the  gluteal  region.  What  affects  the  periphery  of  one  affects  that  of  the 
other.  Both  must  be  physiologic  or  reflexes  will  arise.  By  means  of  the 
pudic  nerve  and  the  small  sciatic  (gluteal)  the  skin  and  muscles  of  the 
pudendum,  perineum  and  anus  are  brought  in  harmonious  relation  with  the 
gluteal  muscles  (of  coition)  and  skin  over  them.  The  genitals,  bladder  and 
rectum  are  supplied  by  the  hypogastric  and  ovarian  plexuses  of  the  sympa- 
thetic, and  the  sympathetic  plexuses  are  joined  by  the  second,  third  and 
fourth  sacral  spinal  nerves. 

Thus  viscera,  skin  and  muscles  of  the  pelvic  region  are  held  in  close 
nerve  association.  The  numerous  reflexes  in  the  pelvic  region  of  patients 
will  bear  close  observation  in  affections  of  the  pudendum,  bladder  and 
rectum.  Pain  may  be  experienced  in  the  perineum,  in  the  gluteal  region  or 
down  the  thigh.  The  explanation  of  this  arises  from  the  fact  that  all  these 
parts,  skin  of  pudendum,  anal  region,  part  of  the  thigh  and  gluteal  region 
are  supplied  by  the  pudic  and  small  sciatic  nerves,  which  come  from  the 
same  plexus  that  gives  off  branches  to  supply  the  viscera,  pudendum,  bladder 
and  rectum.  Thus  the  pelvic  viscera  and  the  skin  of  the  gluteal  region  and 
thigh,  or  perineum  and  external  genital  region,  are  held  in  association  by  the 
branches  of  the  same  spinal  nerves.  The  pain  felt  in  the  urethra  by  a  woman 
with  calculus  in  the  bladder  is  due  to  the  fact  that  the  trigonal  nerve  plexus 
which  supplies  both  trigone  and  urethra,  is  prolonged  to  terminate  in  the 
distal  end  of  the  urethra.  Pain  generally  is  felt  at  the  periphery  of  nerves, 
and  hence  the  irritation  of  calculus  in  the  trigone  is  experienced  in  the 
urethra,  that  is,  at  the  termination  of  the  trigonal  plexus.  The  sigmoid, 
two  inches  above  the  anus,  is  provided  with  very  little  sensation,  while  the 
last  two  inches  in  the  anus  is  very  sensitive.  This  is  observed  by  the  slight 
pain  in  high  malignant  growth  or  other  swellings  of  the  rectum,  by  the  little 
pain  of  large  collections  of  hardened  feces.  Also  by  the  little  pain  induced 
by  perforation  of  the  sigmoid  during  the  administration  of  an  enema.  Its 
sensation  is  limited,  like  all  viscera  supplied  by  the  sympathetic.  The 
relation  of  nerve  mechanism  between  anus  and  the  neck  of  the  bladder  is 
strikingly  intimate.  Hemorrhoidal  operations  are  accompanied  by  urine 
retention  and  bladder  operations  by  rectal  tenesmus. 

This  intimate  nerve  relation  between  rectum  and  the  neck  of  the  bladder 
is  chiefly  due  to  the  fourth  sacral  nerve,  which  supplies  the  neck  of  the 
bladder  and  then  passes  on  to  supply  the  anal  skin,  levator  ani,  and  anal 
sphincter.  The  third  sacral  nerve  sends  a  large  branch  to  terminate  in  the 
body  of  the  bladder,  but  is  not  related  to  the  levator  ani  and  sphincter  ani 
muscles.  The  urethral  mucosa,  the  muscles  of  the  pudendum,  and  the  chief 
part  of  the  skin  of  the  pudendum  perineum  and  anus  are  supplied  by  the 
internal  pudic  nerve  from  the  sacral  plexus.  The  sacral  plexus  emits  the 
gluteal  nerves  which  supply  the  gluteal  muscles.  It  also  gives  off  the  inter- 
ior  pudendal    (branch   of  the  small    sciatic),    which    supplies    directly    the 


280  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

perineum.  Hence  the  external  genitals  and  the  gluteal  muscles  are  in 
intimate  nerve  association. 

Hilton  struck  by  the  peculiar  ending  of  the  inferior  pudendal  nerve  called 
it  the  nerve  of  coition.  The  genito-crural  and  ilio-inguinal  are  from  the  lum- 
bar plexus  and  supply  the  inguinal  and  vulvar  regions.  The  ilio-hypo- 
gastric  supplies  the  hypogastric  and  groin  region. 

With  diseased  condition  of  the  region  supplied  by  the  genito-crural  and 
ilio-inguinal  nerves,  it  is  explainable  how  women  suffer  by  reflex  action  in 
the  region  supplied  by  the  ilio-hypogastric  and  ilio-inguinal  nerves — the 
inguinal  region.  Many  women  mistake  the  inguinal  and  hypogastric  pain 
for  ovarian  disease.  Irritation  in  the  perineum  or  rectum  may  be  followed 
by  priapism.  Adhesions  about  the  glans  clitoridis  or  accumulated  secretions 
under  the  prepuce  may  provoke  not  only  local  disturbances  in  the  bladder  and 
rectum  but  induce  genital  disturbances.  The  pain  felt  through  perineal 
abscess  in  the  gluteal  region  and  in  the  thigh  may  be  explained  by  the  press- 
ure of  the  inferior  pudendal  nerve  in  the  perineum.  In  neuritis  brought  on 
by  trauma  of  the  inferior  pudendal  nerve  due  to  much  sitting  on  hard  seats, 
the  pain  may  be  felt  in  the  perineum  and  the  region  supplied  by  that  nerve. 

Dissection  discloses  the  inferior  pudendal  nerve  crossing  the  gluteal 
region  toward  the  perineum,  close  to  the  ischial  tuberosity,  where  it  is  liable 
to  occasional  injury  with  enlarged  pudendo  vaginal  glands.  Some  patients 
do  not  sit  down  comfortably  on  account  of  the  irritation  of  the  periphery  of 
the  inferior  pudendal  nerve. 

However,  the  pain  may  be  aroused  at  the  ischial  tuberosity,  by  an 
inflamed  bursa  or  local  traumatic  neuritis.  Pain  in  the  knee-joint  from  hip- 
joint  disease  is  an  ever  living  example  of  a  reflex,  pain  starting  at  the  peri- 
phery of  the  one  branch  of  a  nerve  trunk,  and  experiencing  the  pain  at  the 
periphery  of  another  branch  of  the  same  trunk.  The  branches  of  nerve  trunks 
(or  plexuses)  supply  groups  of  muscles  and  skin  in  widely  distributed  regions 
for  the  purpose  of  associating  them  in  function.  For  example,  the  lumbar 
plexus  associates  the  skin  of  the  external  genitals  with  the  skin  of  the  gluteal 
region  by  means  of  its  branches  supplying  both  regions,  as  the  genito-crural, 
ilio-inguinal  and  ilio-hypogastric. 

The  sacral  plexus  associates  the  action  of  the  muscles  (and  skin)  of  the 
external  genitals,  perineum,  and  anus  with  the  gluteus  maximus,  through 
branches  of  the  same  plexus  supplying  both  regions.  The  pudic,  a  branch 
of  the  second,  third  and  fourth  sacral  spinal  nerve,  supplies  the  external 
genitals,  perineum  and  anus,  while  the  gluteal  (smaller  sciatic),  a  branch  of 
the  second,  third  and  fourth  sacral,  supplies  the  gluteus  maximus  muscle  (of 
coition).  Finally  to  perfect  a  balanced  nerve  association  between  muscles 
and  skin  of  the  external  genitals  and  gluteal  region,  the  inferior  pudendal 
nerve  actually  joins  the  periphery  of  the  two  regions. 

A  reflex  is  a  disturbance  in  a  distant  part  from  some  local  peripheral 
irritation.  The  pelvic  viscera  are  liable  to  trauma  and  infection  during  the 
childbearing  period  from  exposed  mucosa  and  serosa,  and  this  traumatic  or 
infection  atrium  becomes  a  fruitful  source  for  reflex  distribution,    through 


RELATION  OF  SPINAL  TO  SYMPATHETIC 


281 


disturbed  pelvic  mechanism,  due  to  cicatricial  contraction  and  subsequent 
dislocation.  The  irritation  is  transmitted  to  the  abdominal  brain,  where  it 
is  reorganized  and  emitted  to  the  organs  of  the  abdomen  and  chest,  disturb- 
ing their  rhythm,  secretion,  absorption,  sensation  and  nutrition.  The 
visceral  rhythm  becomes  irregular,  secretion  and  absorption  become  exces- 
sive, deficient,  or  disproportionate  and  the  blood  becomes  waste  laden.  The 
patient  is  forced  slowly  or  rapidly  through  definite,  though  irregular,  stages 
of  disease  (traumatic  or  infection  atrium),  irri- 
tation, indigestion,  malassimilation,  malnutrition, 
anemia,  neurosis  and  psychosis.  The  nerve 
mechanism  between  ovary,  genitals  and  kidney 
is  very  intimate.  The  ovarian  plexus  originates 
from  the  renal  and  hypogastric,  which  connec- 
tion directly  associates  the  kidney  with  the  inter- 
nal genitals,  and  accounts  for  the  disturbed 
functional  relation  of  kidney  and  internal  gen- 
itals during  menstruation  and  pregnancy  (pain, 
albumen,  and  vomiting).  The  intimate  associa- 
tion of  nerve  relation  between  kidney  and  inter- 
nal genitals  is  manifest  in  diseases  of  either  organ. 
In  menstruation  there  is  a  pain  in  the  renal  re- 
gions. Congestion  of  one  organ  produces  con- 
gestion or  anemia  in  the  other  (reflex  action). 
Renal  calculus  or  nephritis  causes  pain  and  re- 
traction of  the  testicle,  and  of  course  similar 
disturbances  arise  in  the  ovary,  though  not  so 
easily  demonstrated.  Ovarian  disease  may  cause 
pain  in  the  rectum  (supplied  by  the  hypogastric). 
The  ovarian  and  hypogastric  plexus  have  direct 
communication  with  the  abdominal  brain,  and 
hence  the  severe  shock  from  injury  to  the  ovary, 
uterus,  or  rectum,  and  especially  the  tendency  to 
vomit.  The  internal  genitals  (ovary,  oviduct, 
and  uterus)  are  in  just  as  intimate  and  profound 
connection  with  the  great  abdominal  brain  as  the 
enteron,  and  in  trauma  or  infection  of  the  gen- 
itals or  enteron,  will  have  like  severe  manifesta- 
tions of  general  disturbances. 


CUTANEOUS   NERVES  OF 
THORAX   AND   AB- 
DOMEN 


Fig.  64.  The  cutaneous 
nerves  of  the  thorax  and  abdo- 
men, viewed  from  the  side.  (1) 
Ilio-hypogastric.  (2)  Ilio-ingui- 
nal.  (4)  Anterior  cutaneous  of 
last  thoracic.  (10)  Lateral  cu- 
taneous of  last  thoracic.  (9) 
External  oblique  muscle. 
(Henle). 


I.       PELVIC  NERVES  (CEREBROSPINAL). 

The  sacral  plexus  really  terminates  in  two  great  branches,  the  sciatic  for 
the  lower  limb  and  the  pudic,  which  is  a  genital  nerve,  supplying  the 
internal  and  external  genitals. 

Patients  suffer  especially  in  two  regions,  viz. :  (a)  the  hypogastric  region, 
(b)  the  lumbo-sacral  region.  The  explanation  is  that  the  uterus  by  dragging 
or  pressing  on  the  sacral  spinal  nerves,  induces  pain  in  the  lumbo-sacral  re- 


282  THE   ABDOMINAL   AND   PELVIC  BRAIN 

gions  and  the  pain  is  reflected  from  the  lumbar  cord  along  the  ilio-hypogastric, 
ilio-inguinal,  and  genito-crural  nerves,  branches  of  the  lumbar  plexus  to  the 
hypogastric  and  inguinal  region. 

The  lumbar  nerves  supplying  the  hypogastric  and  inguinal  regions  are 
all  branches  of  the  same  trunks — the  lumbar  plexuses. 

The  irritation  of  the  periphery  of  any  branch  liable  to  be  reflected  on  any 
other  branch  of  the  same  trunk.  Irritation  of  the  sacral  nerves  is  liable  to 
be  reflected  from  the  common  lumbar  trunk  to  the  branches  of  the  hypogas- 
tric and  inguinal  region.  However  the  complaint  of  pain  in  the  hypogastric 
or  inguinal  region  may  be  only  in  the  skin  and  purely  hyperesthetic  (hysteric) 
in  character. 

Gynecologic  patients  complain  of  a  triumvirate  of  pain,  viz. :  in  the 
lumbo-sacral  region,  in  the  hypogastrium,  and  in  the  head.  The  lumbo-sacral 
region  is  the  great  central  depot  of  gynecologic  pain.  It  is  the  central  tele- 
graphic station  where  irritated  genitals  first  tell  their  story.  In  this  case,  a 
sympathetic  nerve  which  supplies  the  genitals  relates  the  story  to  the  cerebro- 
spinal axis — a  nerve  of  another  tongue.  It  matters  little  what  disease, 
endometritis,  myometritis,  endosalpingitis,  or  peritonitis  attacks  the  pelvis, 
the  lumbo-sacral  pain  is  the  characteristic  pain.  The  lumbo-sacral  region  is 
the  sensorium  for  pelvic  disturbances.  The  nerves  in  relation  are  the  lumbar 
plexus,  anterior  and  posterior,  the  hypogastric  plexus  connected  to  the  lum- 
bar plexus  by  the  rami  communicantes,  and  the  sacral  plexus.  In  the  hypo- 
gastric region  the  ilio-inguinal,  ilio-hypogastric  and  genito-crural  play  the 
role.  The  last  three  have  cutaneous  branches,  and  often  the  skin  sensation 
.  is  mistaken  for  ovarian  or  other  genital  pain.  Branches  of  the  intercostal, 
lumbar,  and  sacral  nerves  supply  the  peritoneum,  but  conduct  chiefly  to  the 
sacro-lumbar  region. 

Extreme  precautions  are  required  to  discriminate  between  pain  located 
in  the  skin  over  an  organ  and  pain  in  the  organ  itself.  This  may  relate  to 
viscera  or  tumors,  but  is  especially  true  of  the  kidney.  I  have  performed 
nephro-lithotomy  for  pain  in  the  kidney,  with  the  supposition  that  a  calculus 
existed.  No  calculus  was  found,  and  the  intense  hyperesthesia  of  the  skin 
over  the  kidney  remained  long  afterward.  Grave  diagnostic  or  operative 
errors  may  be  committed  by  mistaking  intense  and  persistent  cutaneous 
hyperesthesia  for  disease  underlying  viscera  and  structures.  The  anesthetic 
and  hyperesthetic  zones  should  be  mapped.  It  is  well  known  among  experi- 
enced gynecologists  that  some  peritoneal  cysts  are  very  painful.  The  chief 
painful  cysts  are  located  along  the  oviducts  and  the  two  sides  of  the  ligamen- 
tum  latum.  This  is  in  accord  with  an  observation  that  the  chief  suffering  of 
gynecologic  patients  is  from  pelvic  peritonitis,  i.  e.,  from  dislocated  or  dis- 
turbed pelvic  mechanism.  The  peritoneal  cysts,  with  their  contents,  are 
doubtless  of  an  inflammatory  character.  The  pudic  nerve  is  the  source  of 
motion  to  the  muscles  of  the  perineum,  anus,  bladder,  urethra  and  vagina. 
It  is  a  source  of  sensation  to  the  integument  of  the  perineum,  pudendum  labia, 
mucosa  of  the  clitoris  and  urethral  mucosa.  Irritation  of  the  external  genitals 
creates  a  reflex  in  the  spinal  cord  which  results  in  turgidity  of  the  genitals 


RELATIOX  OF  SPIX.-1L   TO  SYMPATHETIC 


883 


and  finally  a  sense  of  musclar  contraction  in  these  parts  of  the  genitals  sup- 
plied by  the  musclar  branches  of  the  pudic  nerve.  The  integument  and 
immediately  underlying  muscles  are  always  supplied  by  branches  of  the  same 
nerve  trunk. 

The  irritation  of  the  nerves  of  the  genital  integument  (cutaneous  branches 
of  the  pudic)  induces  contractions  of  the  perineal,  levator-anal,  anal,  and 
vaginal  muscles  (musclar  branches  of  the 
pudic)  which  assist  in  expulsion  of  the  secre- 
tion of  the  vulval  glands,  especially  the 
vulvovaginal.  Occasionally  masturbation 
in  the  female  may  be  prevented  by  blister- 
ing the  mucosa  of  the  clitoris,  making  it  so 
tender  that  the  subject  will  cease  manipu- 
lation. 

In  certain  reported  cases  of  fracture  of 
the  vertebral  column,  irritation  of  portions 
of  the  spinal  cord  left  intact  distal  to  the 
seat  of  fracture  will  induce  turgidity  of  the 
genitals  resembling  erections.  The  expul- 
sion of  the  last  drop  of  urine  is  a  reflex  act 
due  to  the  irritation  of  the  urine  on  the 
sensory  pudic  nerves  in  the  urethral  mucosa, 
reflecting  it  to  the  spinal  cord,  whence 
the  force  returns  on  the  (motor)  musclar 
branches  of  the  pudic,  expelling  all  the 
urine  from  the  urethra. 

The  rectum  produces  sympathetic  dis- 
ease in  adjacent  viscera,  as  incontinence  of 
urine,  involuntary  emission  and  neuralgic 
pain.  The  explanation  arises  from  the  dis- 
tribution of  the  pudic  nerve  to  the  integu- 
ment about  the  anus,  which  permits  reflex 
motor  impulses,  from  rectal  irritation  trans- 
mitted to  the  spinal  cord,  to  be  reflected  to 
the  adjacent  genito-urinary  organs  and  as- 
sociated muscles. 

The  small    sciatic    nerve    supplies   the 
gluteus  maximus  and  sends  a  branch  (the 
inferior  pudendal)  to  the  perineum,  puden- 
dal and  vagina.     This  explains  the  relation  in  coition,  of  the  genitals  and  the 
gluteus  maximus  muscle.     Also  it  may  explain  perineal  irritation  from  disease 
along  the  trunk  of  the  inferior  pudendal,  as  hardened  tissue,  which  may  arise 
in  subjects  of  sedentary  habits: 

The  periphery  of  the  ilio-inguinal  and  ilio-hypogastric  which  in  general 
is  the  integument  of  the  lower  abdomen,  may  be  the  seat  of  neuralgia;  or  it 
may  be  the  seat  of  hyperesthesia  or  anesthesia.     The  pain  may  be  paroxys- 


VENTRAL   DIVISIONS  OF  DOR- 
SAL NERVES 

Fig.  65.  A  view  of  the  anterior 
division  of  the  dorsal  nerves.  The 
cut  shows  the  nerves  distributed  to 
the  muscles  and  skin  of  the  abdomen. 
It  may  be  easily  noted  how  an  irrita- 
tion on  the  skin  passes  to  the  spinal 
cord,  and  thence  to  the  abdominal 
muscles,  putting  them  on  tension  to 
protect  underlying  viscera.  Hirsch- 
field  and  Leville.) 


284  THE  ABDOMINAL  AND  PELVIC  BRAIN 

mal,  radiating  along  the  course  of  the  nerves.  Painful  points  may  be  detected 
near  the  spinous  processes  of  the  lumbar  vertebra  (lumbar  point),  near  the 
middle  of  the  iliac  crest  (iliac  point),  near  the  external  inguinal  ring  (hypo- 
gastric point),  in  the  inguinal  canal  (inguinal  point),  and  finally  in  the  labial 
points.  These  are  Valleix's  puncta  dolorosa,  or  points  of  tenderness  along 
the  course  of  nerves. 

The  chief  feature  for  the  gynecologist,  is  the  periphery  of  the  ilio- 
hypogastric and  ilio-inguinal  nerves  in  anesthesia  and  hyperesthesia  of  the 
skin  of  the  hypogastric  and  inguinal  regions.  The  skin  of  the  abdomen  prox- 
imal to  the  umbilicus  is  supplied  in  general  by  the  distal  intercostal  nerves, 
which  may  be  termed  the  respiratory  region.  The  skin  distal  to  the  umbilicus 
is  supplied  by  the  ilio-hypogastric  and  ilio-inguinal,  which  may  be  called  the 
abdominal  region. 

The  genito-crural  and  dorsal  branches  of  the  lumbar  nerves  aid  in  fur- 
nishing motor  power  to  the  region  distal  to  the  umbilicus.  The  skin,  mus- 
cles, and  peritoneum  of  the  abdomen  are  supplied  by  branches  of  the  same 
trunks,  so  as  to  preserve  harmony  of  motion  and  association  of  sensation, 
insuring  visceral  protection. 

For  example,  if  cold  water  be  dashed  against  the  belly,  the  skin  sensa- 
tion is  transmitted  to  the  spinal  cord,  and  reflected  to  the  abdominal  muscles, 
causing  an  immediate  rigidity,  for  the  protection  of  adjacent  and  underlying 
viscera. 

The  harmony  of  the  skin,  muscles  and  peritoneum  (viscera)  explains  how 
massage  assists  in  curing  constipation  For  example,  skin  irritation  on  the 
abdomen  is  transmitted  to  the  cord,  whence  (a)  it  is  reflected  to  the  abdomi- 
nal muscles,  producing  action  which  aids  in  fecal  expulsion ;  (i>)  the  reflected 
force  induces  visceral  peristalsis.  This  is  motor.  It  appears  also  that  the 
sensory  condition  of  the  skin  is  in  harmony  with  the  sensory  condition  of  the 
underlying  viscera.  Diseased  underlying  abdominal  viscera  are  apparently 
accompanied  with  correspondingly  disturbed  sensory  cutaneous  areas. 

The  genito-crural  nerve  supplies  only  one  muscle,  the  round  ligament, 
and  finally  supplies  the  labia.  The  periphery  of  any  of  the  ventral  divisions 
of  the  lumbar  plexus  (the  ilio-hypogastric,  ilio-inguinal,  genito-crural  and 
external  cutaneous)  may  show  disturbances  of  motion  or  sensation  by  inflam- 
matory products,  compressing  any  part  of  their  trunks.  In  psoas  abscess  the 
genito-crural  and  the  external  cutaneous  might  show  a  disturbed  periphery, 
as  well  as  other  branches  of  the  lumbar  plexus.  The  practical  matters  for 
the  gynecologist  to  determine  in  the  complicated  nerve  mechanism  of  the 
pelvis  and  associated  relations,  are:  1.  Map  on  the  abdomen  the  areas  of 
anesthesia  and  hyperesthesia.  2.  Hyperesthesia  of  skin  should  not  be  mis- 
taken for  a  diseased  underlying  viscus,  as  the  ovary  or  kidney.  3.  Areas  of 
anesthesia  and  hyperesthesia  may  change  from  day  to  day.  4.  Hysteria  has 
certain  stigmata,  viz.:  (a)  anesthesia  of  the  conjunctiva  bulbi;  {b)  anesthesia 
of  the  mucosa  of  pharynx;  (c)  anesthesia  or  hyperesthesia  of  skin  (especially 
of  abdomen);  {d)  sudden  paresis  or  exacerbation  of  muscle  (knee,  globus, 
tongue,  knotting  of  belly  muscles);   (e)  occasional  mental  phenomena,  and  (/) 


RELATION   OF  SPINAL   TO  SYMPATHETIC 


285 


disturbance  of  special  sense,  as 
sudden  blindness  or  excessive 
bearing.  Some  of  these  six 
stigmata  must  be  present  to 
diagnose  hysteria.  5.  Much 
of  the  hypogastric  pain  com- 
plained of  by  subjects  is 
located  in  the  skin  of  the 
inguinal  and  hypogastric  re- 
gion. This  pain  may  be 
caused  by  sensory  disturb- 
ances in  the  skin  only,  or  by 
reflex  disturbances  from  dis- 
eased genitals,  through  the 
anterior  branches  of  the  lum- 
bar plexus.  6.  Gynecologic 
patients  complain  of  pain :  {a) 
in  the  sacro-lumbar  region 
from  diseased  genitals  irri- 
tating the  periphery  of  the 
sacro-lumbar  nerves;  (I?)  pain 
in  the  hypogastric  and  ingui- 
nal region  from  irritation  of 
the  genitals  passing  to  the 
lumbar  cord,  whence  it  is  re- 
organized and  reflected  on  the 
anterior  branch  of  the  lumbar 
plexus;  and  (c)  pain  in  the 
head  through  reflexes  in  dis- 
eased genitals.  Perhaps  the 
occipitalis  major  and  minor 
constitute  part  of  this  nerve 
route.  7.  The  stomach  is  one 
of  the  chief  organs  to  suffer 
reflexly  from  diseased  genitals 
through  the  direct  route  of 
the  hypogastric  plexus,  ex- 
tending from  the  genitals  to 
the  abdominal  brain,  whence 
it  is  reorganized  and  sent  to 
the  stomach,  over  the  gastric 
plexus.  The  nerves  which 
supply  the  internal  pelvic  vis- 
cera are  located  in  general 
between  the  pelvic  fascia  and 
the  peritoneum. 


Fig.  66.  (From  Byron  Robinson's  life-size  chart  of 
the  Sympathetic.)  Represents  the  abdominal  brain 
and  adjacent  ganglia.  (55)  A  ganglion  of  the  dorsal 
lateral  chain.  (61)  Splanchnic.  {96  and  97)  Rami  com- 
municantes.     (67)  Branches  of  right  vagus  to  stomach. 

(69)  Trunk  of  right  vagus  entering  abdominal  brain. . 

(70)  Phrenic  nerve  on  phrenic  artery.  (71)  Right  ab-' 
dominal  brain.  (72)  Left  abdominal  brain.  (73)  Gastric 
artery.  (74)  Splenic  artery.  (75)  Hepatic  artery.  (76) 
Right  great  splanchnic.  (77)  Ad-renal.  (79)  Supra- 
renal nerves  (6).  (82)  Inferior  renal  ganglion.  (83) 
Superior  renal  ganglion.  (84,  85,  86  and  87)  Ganglia 
on  renal  artery.  (88)  Renal  artery.  (89,  90  and  91) 
Lumbar  nerves.  (96,  97  and  98)  Rami  communicantes. 
(101, 102  and  103)  Lumbar  lateral  chain  of  ganglia.  (106) 
Superior  mesenteric  artery  surrounded  by  the  abdom- 
inal brain.  (107,  108  and  109)  Genital  ganglia.  (110 
and  111)  Genital  ganglia  (ovarian)  as  well  as  (112,  113 
and  114)  Genito-rectal  ganglia.  (167).  Nerves  around 
the  ovarian  artery.  (171)  First  lumbar  nerve.  (172) 
Second.  (173)  Third.  (176)  First.  (177)  Second,  and 
(178)  Third  lumbar  ganglia.  (182)  Genital  ganglion. 
(183)  Inferior  mesenteric  artery.  (185)  Aortic  branch 
of  abdominal  brain.  (186)  Ending  of  left  great 
splanchnic  in  abdominal  brain.  (187)  Superior,  and 
(188)  inferior  (left)  renal  ganglia.  (189,  190  and  191) 
(left)  Renal  ganglia. 


286  THE  ABDOMIXAL  AXD  PELVIC  BRALX 

The  cervix  and  vagina  are  mainly  supplied  by  branches  from  the  third 
and  fourth  sacral  nerves.  The  pudendum  is  supplied  by  the  pudic,  which  is 
chiefly  composed  of  the  third  sacral  nerve.  The  pudic  nerve  passes  from  the 
pelvis  from  the  third  sacral  by  the  way  of  the  large  sacro-sciatic  foramen, 
winds  around  the  spine  of  the  ischium,  and  re-enters  the  pelvis  through  the 
lesser  sacro-sciatic  foramen;  it  is  thus  removed  from  the  dangers  of  the 
trauma  due  to  labor.  The  nerve  directly  traumatized  by  labor  is  the  obtur- 
ator. When  the  child's  head  engages,  the  obturator  muscles  of  the  thighs 
act  by  closing  and  flexing  them.  The  pudic  nerve  sends  branches  to  the 
clitoris,  to  the  pudendum,  to  the  perineum,  and  to  the  rectum.  Practically 
the  sacral  plexus  terminates  in  the  two  branches,  the  pudic  (genital)  and 
sciatic  (limb). 

In  teaching  I  have  frequent!}*  represented  the  pudic  nerve  by  the  hand. 
For  example,  the  arm  represents  the  nerve  itself,  the  thumb  represents  the 
great  vesical  nerve  just  before  the  pudic  passes  from  the  pelvis;  after  the 
pudic  has  re-entered  the  pelvis  and  passed  along  the  ramus  of  the  pubes,  the 
index  finger  represents  the  branch  to  the  clitoris,  the  middle  finger  the  branch 
to  the  pudendum,  the  ring  finger  the  branch  to  the  perineum,  and  the  little 
finger  the  branch  to  the  rectum.  Thus  the  digits  of  the  hand  can  vividly 
represent  the  branches  of  the  pudic  nerve. 

It  can  also  be  remembered  that  the  pudendal  nerve,  a  branch  of  the 
small  sciatic  nerve,  sends  branches  to  the  anus,  perineum,  pudendum  and 
clitoris,  which  unite  with  similar  branches  from  the  pudic  to  supply  the  same 
organs.  There  is  a  wonderful  design  in  the  union  of  the  periphery  of  the 
pudendal  and  the  pudic  nerves. 

The  lesser  sciatic  nerve  supplies  but  one  muscle  (gluteus  maximus),  and 
then  gives  off  a  branch,  the  pudendal,  which  directly  supplies  the  external 
genitals  and  rectum.  This  arrangement  of  the  nerve  supply  brings  the  gluteus 
maximus  muscle  and  the  skin  of  the  genitals  in  direct  relation.  Irritation  of 
the  genitals  will  induce  contraction  of  this  muscle.  Thus  the  gluteus  maxi- 
mus muscle  must  be  considered  (anatomically  and  physiologically)  the  muscle 
of  coition.     Observation  of  copulating  animals  will  confirm  this  view. 

The  external  genitals  are  supplied  by  the  plexus  pudendus.  A  small  seg- 
ment is  supplied  by  the  fifth  sacral  nerve  through  the  plexus  sacro-coccygeus. 
The  chief  nerves  concerned  in  the  supply  of  the  external  genitals  are:  1. 
The  medial  hemorrhoidal  nerve;  (2)  the  inferior  vesical  nerve,  which  sends 
fibers  to  the  base  of  the  bladder  and  the  urethra,  to  the  vagina  and  middle 
portion  of  the  rectum:  3.  The  internal  pudic  nerve,  which  follows  the  inter- 
nal pudic  artery  and  divides  into  {a)  inferior  hemorrhoidal,  which  supplies 
the  internal  and  external  anal  sphincters  and  the  skin  of  the  anus;  (b)  the 
perineal  nerve,  which  supplies  the  skin  on  the  perineum,  the  musculus  trans- 
versa perinei,  sphincter  ani  externus,  sphincter  vaginae  and  also  the  labia 
and  the  vestibulum  vaginae;  (c)  the  dorsal  nerve  of  the  clitoris,  which  passes 
between  the  sphincter  vaginae  and  ischio-cavernosus  under  the  symphysis 
pubis  to  the  proximal  border  of  the  clitoris,  whence  it  sends  numerous  fine 
fibers  to  the  skin  as  well  as  to  the  cavernous  tissue. 


ANATOMY   OF   THE   SYMPATHETIC 


287 


II.       THE  SYMPATHETIC  NERVES. 

The  sympathetic  nerve  consists  of,  viz.:  (a)  ganglia  (lateral  chain);  (/;) 
conducting  cords;  (<)  three  ganglionic  plexuses  located  in  the  chest  (thoracic 
plexus),  abdomen  (abdominal  brain),  and  pelvis  (pelvic  brain);  and  («•/)  auto- 
matic visceral  ganglia.  The  conducting  cords  are  not  sheathed;  they  are 
non-medullated.  The  ganglia,  composed  of  nerve  cells,  are  little  brains. 
They  are  reorganizing  centers,  receiving  sensations  and  sending  out  motion. 
The  abdominal  and  pelvic  brains  and  the  ganglionic  plexuses  are  simply  large 
brains  or  aggregations  of  nerve  cells. 


Fig.  G7.  (Eyron  Robinson.)  From  author's  life-size  chart  of  the  Sympathetic.  Repre- 
sents the  cervico-uterine  ganglion.  ( — )  The  pelvic  brain.  (127)  Second.  (128)  Third, 
and  (129)  Fourth,  sacral  nerves  (left).  (131)  Second.  (132)  Third.  (133)  Fourth,  sacral 
nerves  (right).  Note  the  connection  of  the  second,  third,  and  fourth  sacral  nerves  to  the 
pelvic  brain.  (137  and  138)  Second  and  third  sacral  ganglia.  (139)  Branches  from  the 
second  sacral.  (140)  Branches  from  the  third  and  fourth  sacral  nerves  to  the  pelvic  brain 
(141  and  142).  The  pelvic  brain  or  cervico-uterine  ganglion  is  marked  (141,  142,  143,  144)  and 
(145)  branches  of  it.  Third  sacral  to  the  levator  ani  muscle  (146).  (147)  Vesical  ganglion. 
(148)  Ureter.  (149)  Bladder.  (150)  Vagina.  (151)  Uterus.  (152)  Nerves  of  bladder.  (153) 
Pudic  nerve.  (158)  Right,  and  (159)  left,  sacral  plexus.  (160)  Branches  of  hypogastric 
plexus  which  do  not  enter  pelvic  brain  before  distribution.  (161)  Fallopian  tube.  (162) 
Ovary.     (163)  Round  ligament.     (164)  Acetabulum.     (165)  Spine  of  ischium. 


A  summary  of  the  abdominal  brain  is:  (a)  It  presides  over  nutrition; 
id)  it  controls  circulation;  (<r)  it  controls  gland  secretion;  (d)  it  presides  over 
the  organs  of  generation,  and  (<?)  it  influences  in  a  dominant  way  the  auto- 
matic visceral  ganglia.  With  nerve  fibers  radiating  on  blood  and  lymph  ves- 
sels and  to  every  abdominal  viscus,  it  is  no  wonder  that  the  abdominal  brain 
has  been  considered  the  center  of  life. 

An  ideal  nervous  system  should  be  a  neuron  and  consist  of  first,  a  gang- 


288  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

lion  cell:  second,  a  conducting  cord,  and,  third  a  periphery.  The  sympathetic 
nervous  system  possesses  the  neuron  or  three-nerve  elements  in  an  eminent 
degree.  The  abdominal  brain  represents  the  central  ganglion  cell.  Its 
thousands  of  cords,  distributing  fibers,  represent  the  conducting  cord,  while 
the  various  automatic  visceral  ganglia  represent  the  periphery. 

The  sympathetic  nerve  supplies  the  uterus,  oviducts,  and  ovaries,  as  they 
possess  rhythm.  Only  viscera  whose  main  nerve  supply  is  sympathetic 
possess  rhythm.  The  cervix  is  supplied  by  the  spinal  nerves,  and  does  not 
possess  rhythm  to  any  marked  degree. 

The  peritoneum  is  supplied  chiefly  by  the  sympathetic  nerves.  The 
main  spinal  nerves  which  supply  the  peritoneum  are  the  peritoneal  branches 
of  the  ilio-inguinal  and  ilio-hypogastric  and  distal  intercostals.  The  sense 
of  localization  in  detail  is  yet  unrecognized  in  the  sympathetic,  which  prepond- 
erates in  the  peritoneum  and  tractus  intestinalis,  while  the  cerebro-spinal 
nerves  are  so  much  in  the  minority  that  they  are  uncertain  in  indicating 
localized  areas. 

The  domain  of  the  sympathetic  nerve  is  beyond  the  control  of  the  will, 
as  the  beating  of  the  heart,  uterine  and  intestinal  contraction,  erection  of 
cavernous  tissue  and  the  systole  and  diastole  of  the  bladder.  Man  cannot 
speculate  on  his  sympathetic  system. 

The  most  interesting  and  delicate  structure  connected  with  the  genitals 
is  the  nervous  apparatus.  This  consists  of  cerebro-spinal  and  sympathetic 
or  non-medullated  nerves.  The  uterus  (body),  oviducts  and  ovaries  are  chiefly 
supplied  by  the  sympathetic  nerves,  while  the  pudendum,  vagina  and  cervix 
are  mainly  supplied  by  the  cerebro-spinal  nerves. 

The  hypogastric  plexus  originates  in  the  abdominal  brain  (solar  plexus), 
and  passes  along  the  aorta.  It  is  increased  by  branches  from  the  lumbar 
ganglia  of  the  lateral  chain  of  the  sympathetic.  The  combined  strands  of 
nerves  now  pass  over  the  bifurcations  of  the  aorta  and  sacral  promontory, 
and  divide  into  two  large  bundles,  each  of  which  passes  dorsal  to  the  perito- 
neum to  the  base  of  the  ligamentum  latum  where  it  reaches  the  side  of  the 
uterus  and  oviducts.  Some  strands  pass  to  the  rectum,  but  this  organ  is 
chiefly  supplied  by  the  nerves  passing  along  the  inferior  mesenteric  artery. 
The  ovarian  plexus  consists  of  nerve  strands  derived  from  the  hypogastric 
plexus  and  the  ganglia  in  the  lumbar  lateral  sympathetic  chain,  and  the  nerves 
passing  along  the  ovarian  artery.  The  ovarian  plexus  supplies  the  ovaries 
and  the  ampulla  of  the  oviducts. 

At  the  periphery  of  the  hypogastric  and  ovarian  plexuses  are  situated 
small  ganglia  along  the  walls  of  the  oviducts  and  uterus,  which  I  have  desig- 
nated "automatic  menstrual  ganglia."  I  have  attempted  to  show  that  these 
ganglia  rule  the  rhythm  of  menstruation.  The  composite  ganglia  located  at 
the  lateral  borders  of  the  cervix  and  vagina  I  have  denominated  the  Pelvic 
Brain. 

The  best  method  to  demonstrate  the  nerves  of  the  uterus  I  have  found 
to  be  the  placing  of  an  infant  cadaver  in  pure  alcohol  for  several  weeks,  when 
the  hypogastric  plexus  can  be  traced  to  its  home  on  the  body  of  the  uterus 


ANATOMY   OF   THE   SYMPATHETIC 


289 


as  plainly  as  though  it  were  composed  of  white  cotton  threads.     The  nerves 
in  the  infant  are  much  larger  in  proportion  to  its  size  than  in  the  adult. 

Here  will  be  presented  a  few  remarks  on  the  anatomy,  physiology,  and 
pathology  of  the  sympathetic  nerve,  showing  the  principal  points  in  gynecol- 
ogy relative  to  the  abdominal  and  pelvic  brain.     They  are  the  result  of  my 


Fig.  68.  (Laville  and  Hirschfield.)  Is  a  cut  to  illustrate  the  nerves  of  the  non-pregnant 
uterus.  (1)  Hypogastric  plexus  lying  on  the  bifurcation  of  the  aorta.  It  divides  to  pass  each 
side  of  the  rectum.  (2)  Rectal  branches  on  rectum  (R).  (3)  Lumbar  ganglia  of  the 
sympathetic.  (4)  Ovarian  plexus.  (5)  Branch  of  the  third  and  fourth  sacral  nerves  passing 
to  the  pelvic  brain  (6  and  7)  before  going  to  the  uterus.  (6  and  7)  Nerve  plexuses  on  the 
vagina  and  rectum.  (8)  Uterine  nerves.  (i>)  Vesical  plexus.  (10)  Trunk  of  it — great  sciatic. 
(11)  Levator  ani  branch.  (12)  Trunk  of  the  pudic  nerve.  (U)  Uterus.  (B)  Bladder.  (S) 
Sacrum.  (D)  Tranversus  perinei  muscle  cut.  This  cut  is  partly  diagramatic,  as  the  nerves 
are  not  distributed  in  the  form  represented  in  the  illustration,  but  represent  more  aggrega- 
tions, as  drawn  by  the  author.     The  nerves  in  Savage's  cut  are  represented  too  richly. 


investigations  of  the  sympathetic  nerve,  which  I  have  dissected  during  the 
last  ten  years.  The  claim  is  that  the  ganglia  of  the  sympathetic  nerve  are 
little  brains;  i.  e.,  they  receive  sensation,  emit  motion,  and  control  secretion. 
They  are  trophic  centers,  and  possess  vaso-motor  power.  They  are  centers 
for  reflex  action,  and  are  endowed  with  a  peculiar  quality  called  rhythm. 

19 


290  THE  ABDOM1XAL   AXD   PELVIC   BRAIX 

The  great  reorganizing  centers  in  the  sympathetic  nerves  are  the  abdomi- 
nal and  pelvic  brain  and  the  three  cervical  ganglia.  Reorganizing  power  of  a 
less  degree  exists  in  the  lateral  chain  of  ganglia  situated  at  the  circumference 
of  the  elliptical-shaped  sympathetic,  and  in  the  collateral  ganglia  in  the  chest, 
abdomen  and  pelvis,  and  also  in  the  ganglia  situated  in  every  viscus  which  I 
have  designated  automatic  visceral  ganglia. 

The  sympathetic  nerve  consists  of  two  lateral  chains  of  ganglia,  extending 
from  the  base  of  the  skull  to  the  coccyx.  Situated  anterior  to  these  chains 
are  collateral  plexuses  known  as  the  cardiac,  abdominal  and  pelvic.  Besides 
these  there  exist  in  all  the  viscera  small  ganglia,  automatic  visceral  ganglia 
— for  example,  the  automatic  hepatic,  cardiac,  menstrual  ganglia. 

The  distribution  of  the  sympathetic  nerve  is  G?)  to  vessels,  {b)  to  glands, 
and  {c)  to  viscera.  It  is  connected  with  the  cerebro-spinal  nerves  by  the  rami 
communicantes.  Its  independence  of  the  cerebro-spinal  axis  is  not  yet  fully 
settled;  but  children  have  been  born  at  term  with  no  cerebro-spinal  axis. 
The  part  of  the  sympathetic  that  appears  to  be  most  independent  of  the 
cerebro-spinal  axis  is  the  cardiac,  abdominal  and  pelvic  plexuses  (brains).  I 
have  kept  the  intestines  of  dogs  in  active  peristaltic  waves  for  nearly  two 
hours  after  death,  in  a  warm  room,  by  tapping  them  with  the  scalpel. 

The  automatic  parts  of  the  sympathetic  to  which  I  wish  to  direct  atten- 
tion are,  the  cervical  sympathetic  ganglia  (superior,  middle,  and  inferior), 
the  abdominal  brain  (the  solar  plexus),  and  the  pelvic  brain  (or  cervico-uterine 
plexus).  Due  consideration  must  be  given  to  the  three  splanchnic  groups: 
(1)  the  cervical  splanchnics,  conducted  to  the  stomach,  heart,  and  lungs 
through  the  spinal  accessory  and  the  vagus;  ("2)  the  abdominal  splanchnics, 
originating  from  the  fourth  dorsal,  running  to  the  second  lumbar,  and  thence 
to  the  abdominal  brain  ;  (3)  the  pelvic  splanchnics,  conducted  to  the  hypogas- 
tric plexus  by  means  of  the  second,  third  and  fourth  sacral  nerves,  to  supply 
the  rectum  and  the  genito-urinary  organs. 

I  have  observed  for  some  time  that  the  connection  of  genital  and  urinary 
systems  with  all  the  great  nerve  centers  is  intimate  and  profound.  For  exam- 
ple, the  organ  which  has  the  most  intimate  connection  with  the  cerebro- 
spinal axis  and  the  abdominal  and  pelvic  brain  is  the  uterus.  The  eye,  too,  is 
closely  connected  with  both  nervous  systems,  and  also  with  the  uterus.  This 
intimate  nervous  connection  of  the  uterus  with  the  nervous  system  increases 
with  the  ascending  scale  of  animal  life. 

The  physiological  function  of  the  sympathetic  nerve  is  rhythm.  The 
sympathetic  nerve  alone  possesses  this  function.  The  power  to  produce 
rhythm  belongs  only  to  a  ganglion.  The  viscera  functionate  rhythmically. 
The  destruction  of  this  periodical  function  causes  disease.  The  organs  which 
have  the  most  pronounced  rhythm  are  those  intimately  connected  with  the 
abdominal  brain.  Chief  among  these  is  the  uterus  and  oviducts.  So  far  as 
I  can  observe,  the  uterus  is  connected  with  the  abdominal  brain  by  twenty  or 
thirty  strong  nerve  strands. 

The  uterus  and  oviducts  have  a  monthly  rhythm,  due  to  the  automatic 
menstrual  ganglia  situated  in  their  walls.     No  doubt  the  higher  physiological 


PHYSIOLOGY    OF   THE   SYMPATHETIC 


291 


orders  originate  in  the  great  abdominal  brain.  The  breaking  of  the  rhythm 
of  one  viscus  disturbs  the  rhythm  of  all  the  rest.  This  is  in  no  organ  so 
significant  as  in  the  uterus, 
because  the  uterus  is  more 
exposed  to  infection  and 
trauma — disease — than  any 
other  viscus.  The  glandular 
endometrium,  the  best  germ 
culture  medium,  is  exposed 
to  the  external  body  service. 
The  liver  has  a  visceral 
rhythm,  through  its  auto- 
matic hepatic  ganglia,  simi- 
lar to  that  of  the  uterus. 
When  new  food  arrives  in 
the  liver  from  the  portal 
vein,  the  cells  of  the  liver 
begin  to  swell,  in  the  per- 
formance of  their  functions 
of  making  bile,  glycogen  and 
urea.  The  hepatic  capsule 
(Glisson's)  and  the  peri- 
toneal covering  being  ex- 
tremely elastic,  the  liver  can 
go  through  its  rhythm  when- 
ever occasion  arises.  When 
the  liver  arrives  at  the  maxi- 
mum point  of  the  rhythm, 
the  cells  having  exhausted 
themselves  in  making  bile, 
glycogen  and  urea,  these 
three  products  are  sent 
home,  (in  the  lumen  of  the 
tractus  intestinalis)  and  the 
cells  begin  to  contract,  Glis- 
son's capsule  begins  to 
shrink,  and  the  peritoneum 
returns  to  its  original  state. 
Then  the  liver  secures  rest 
and  repair,  in  order  to  be 
able  to  accomplish  the  next 
rhythm.  It  is  the  breaking 
of   the   hepatic    rhythm    by 

unfavorable  food  or  distant  reflexes  of  diseased  viscera  that  causes  disease 
of  the  liver.  The  most  prominent  organ  that  induces  irregular  hepatic 
rhythm  is  a  diseased  uterus.     Alcohol,  which  rushes  from  stomach  to  liver 


Fig.  69.  (From  Bryon  Robinson's  life-size  chart  of 
the  Sympathetic.)  Represents  the  upper  or  neck  and 
chest  portion.  (7)  Middle  cervical  ganglion.  (8,  8) 
Inferior  cervical  ganglion.  (13,  14,  15,  16)  Cervical 
nerves.  (17)  First  dorsal  nerves.  (18)  Phrenic.  (19) 
Branch  from  inferior  cervical  to  phrenic.  (20,  21) 
Cardiac  nerves  from  middle  and  superior  cervical 
ganglia.  (22,  22,  and  22)  Cardiac  nerves  from  inferior 
cervical  ganglion.  (23)  Wrisberg's  ganglion  (of  the 
heart).  (24  to  33)  Cervical  rami  communicantes.  (34 
and  35)  Ganglia  on  superior,  middle  and  inferior  car- 
diac nerves  of  the  cervical  ganglia.  (36)  Verteral 
artery.  (37)  Left  subclavian  artery.  (38)  Innominate 
artery.  (39)  Right  subclavian  artery.  (40)  Carotid  ar- 
tery. (41)  Aorta.  (43)  Intercostal  arteries.  (45,  46  and 
47)  Dorsal  lateral  chain  of  ganglia.  (63)  Communi- 
cantes. 


292  THE  ABDOMIXAL   AXD   PELVIC  BRAIN 

through  the  gastric  veins,  taken  without  food,  destroys  the  nice  balance  of 
the  hepatic  rhythm  by  enticing  the  liver  to  go  through  its  rhythm  without 
due  stimulus  or  by  unnatural  stimulus. 

It  is  plain  that  the  heart  goes  through  a  rhythm  by  means  of  the  auto- 
matic cardiac  ganglia  situated  in  its  wall.  These  ganglia  are  known  as  Bid- 
der's, Schmidt's,  Remak's,  and  Ludwig's.  The  vagi  (especially  the  right) 
give  the  heart  the  slow,  steady  beat,  its  sober,  regular  movements  like  a 
pendulum;  but  the  three  cervical  sympathetic  ganglia  rule  the  heart  in  regard 
to  rapidity  and  irregularity.  It  is  the  breaking  of  the  cardiac  rhythm  that 
causes  reflex  heart  trouble.  A  diseased  uterus,  from  the  intimate  and  pro- 
found nerve  connection,  is  preeminently  the  organ  that  disturbs  the  heart 
and  its  rhythm  (by  disturbed  circulation  in  the  coronary  arteries). 

The  digestive  tract  has  its  own  special  rhythm  through  Auerbach's  and 
Billroth-Meissner's  plexuses — the  one  presiding  over  the  peristalsis,  and  the 
other  over  absorption,  secretions.  The  occasion  of  a  digestive  rhythm  is  food. 
The  main  rhythm  occurs  in  the  enteron  and  the  stomach. 

The  bladder  performs  a  rhythm  by  means  of  automatic  visceral  gang- 
lia; it  has  a  diastole  and  a  systole.  The  rhythm  of  the  bladder  is  broken 
when  its  nerves  are  dragged,  as  in  pregnancy. 

The  spleen  performs  its  rhythm  by  its  automatic  splenic  ganglia.  The 
occasion  of  a  splenic  rhythm  is  fresh  food.  The  spleen  accomplishes  its 
rhythm  by  (a)  the  swelling  of  its  tufts  and  substance,  (b)  by  the  expansion  of 
its  elastic  capsule,  and  (c)  by  the  stretching  of  its  peritoneal  covering.  It 
rises  to  a  maximum  and  sinks  to  a  minimum.  It  is  now  in  action  and  now  in 
repose. 

Thus  each  viscus  performs  its  peculiar  rhythm  by  means  of  the  automatic 
ganglia  situated  in  its  substance.  The  higher  physiological  orders  of  the 
abdominal  brain  must,  of  course,  be  obeyed. 

III.       PATHOLOGY. 

We  now  come  to  the  consideration  of  diseased  viscera.  Pathogenesis 
through  the  sympathetic,  in  health  and  disease,  is  by  reflex  action.  Of  course 
we  have  ganglionic  sclerosis,  recognizable  and  non-recognizable  lesions  of  the 
sympathetic,  pigmentation  and  secondary  disease,  etc.,  but  the  great  pathol- 
ogy of  the  sympathetic  nerve  in  gynecology  is  the  transmission  of  reflexes 
from  diseased  viscera. 

We  will  take  for  illustration  a  case  of  uterine  cervical  laceration  occur- 
ring five  years  previous.  The  patient  is  now  a  pale,  anemic,  neurotic  woman, 
unfitted  for  the  labor  of  life.  A  lacerated  cervix  (an  infection  atrium)  is  soon 
followed  by  endometritis.  Irritation  from  this  is  transmitted  over  the  hypo- 
gastric plexus  to  the  abdominal  brain,  where  it  is  reorganized.  It  should  be 
remembered  that  any  irritation  (force,  vibration)  will  travel  on  the  lines  of 
least  resistance,  and  in  the  direction  of  least  resistance  from  the  abdominal 
brain  toward  that  organ  having  the  greatest  number  of  nerve  strands.  The 
irritation  reorganized  will  flash  on  all  the  plexuses.  Reaching  the  liver,  it 
will  disturb  the  hepatic  rhythm,  causing  an  over-production,  an  under-produc- 


PHYSIOLOGY   OF   THE   SYMPATHETIC  293 

tion,  or  an  irregular  production,  of  bile,  gylcogen  and  urea ;  and  finally  the 
functions  of  the  liver  suffer  impairment.  Suppose  we  follow  this  same  uter- 
ine irritation  to  the  digestive  tract.  At  Auerbach's  plexus  it  will  cause  colic, 
lethargy,  or  fitful  peristalsis,  and  at  the  plexus  of  Billroth-Meissner  it  will 
induce  diarrhea,  constipation,  or  development  of  gases — fermentation.  These 
disturbances,  after  a  painful  progress  of  from  six  months  to  two  years,  culmi- 
nate in  indigestion.  Then  comes  malnutrition,  which  results  from  long-con- 
tinued indigestion.  The  third  stage  is  anemia  from  malnutrition.  The  fourth 
stage  is  neurosis:  the  ganglia  have  been  long  bathed  in  waste-laden  blood. 
Finally  psychosis  may  arise. 

Hence  endometritis  may  induce:  {a)  indigestion,  (/>)  malnutrition,  (c) 
anemia,  (<-/)  neurosis,  and  (r)  psychosis. 

Again,  consider  heart  palpitation  at  the  menopause.  It  can  be  explained 
by  reflex  action.  The  child-bearing  period  of  a  woman  is  thirty  years.  During 
that  time  regular  monthly  forces  have  been  transmitted  over  the  hypogastric 
plexus  to  induce  uterine  and  oviductal  rhythm.  Now,  at  the  menopause,  the 
hypogastric  plexus  degenerates  and  will  not  carry  the  forces,  which  conse- 
quently accumulate.  The  accumulated  forces  in  the  abdominal  brain  go  up 
the  splanchnic  to  the  three  cervical  ganglia,  where  they  are  reorganized  and 
flashed  to  the  heart,  causing  it  to  work  either  too  rapidly,  or  fitfully.  This 
explains  palpitation  at  menopause. 

Exactly  the  same  explanation  suffices  for  liver  disease  during  this  period. 

At  the  menopause  the  heat,  circulatory,  and  sweet  centers  are  irritated, 
and  the  woman  has  flashes  of  heat,  flushes  of  blood  and  "spells"  of  sweating. 

Pigmentation  is  also  from  reflex  action:  the  irritation  spending  its  main 
force  on  the  liver  and  the  spleen,  causes  pigmentation. 

The  genitals  are  profoundly  supplied  by  the  sympathetic.  Observe  the 
double  lateral  supply  and  also  the  central  hypogastric  supply.  There  are  two 
ovarian  ganglia  at  the  origin  of  the  ovarian  arteries.  There  are  two  giant 
pelvic  brains  or  cervico-uterine  ganglia,  and  these  pelvic  brains  are  connected 
by  some  thirty  strands  to  the  great  abdominal  brain.  The  uterus,  the  popu- 
lar center  of  the  genitals,  though  anatomically  the  ovary  is  the  real  central 
genital  organ,  is  supplied  from  the  abdominal  brain  by  means  of  the  lateral 
hypogastric  plexus  chain,  and  the  second,  third,  and  fourth  sacral  nerves. 
The  pelvic  brain  demedullates  the  nerves,  so  that,  though  the  three  sacral 
nerves  supply  the  uterus,  it  is  accomplished  by  first  sending  the  three  sacral 
nerves  through  the  pelvis,  where  they  are  demedullated  before  reaching  the 
uterus.  In  an  anatomic  and  physiologic  sense  the  pelvic  brain  is  of  extreme 
importance  on  account  of  its  vascular  influence  over  the  uterus  and  oviducts, 
on  account  of  its  control  to  some  extent  of  uterine  and  oviductal  rhythm,  and 
on  account  of  its  influence  on  the  nourishment  of  the  uterus  and  oviducts. 
Also,  perhaps,  parturition  is  instigated  by  pressure  or  trauma  of  the  cervico- 
uterine  ganglion  by  the  expanding  cervix ;  in  other  words,  trauma  to  the  pel- 
vic brain.  There  are  adjacent  ganglia  to  the  pelvic  brain  which  influence 
the  uterus,  bladder  and  vagina,  holding  these  three  organs  in  intimate  connec- 
tion.    There  is  the  plexus  vesicalis  (vesical  ganglion),  the  hypogastric  plexus, 


294  THE  ABDOMINAL  AND  PELVIC  BRAIN 

and  the  plexus  uterovaginal  (pelvic  brain),  all  three  closely  connected  ana- 
tomically and  also  connecting  anatomically  and  physiologically  the  bladder, 
cervix  and  uterus. 

It  is  daily  gynecologic  observation  that  the  uterus  and  bladder  functionate 
together  through  nerve  connection — especially  the  sympathetic.  However, 
the  chief  function  of  the  pelvic  brain  is  to  rule  the  uterus,  as  will  be  observed, 
by  noting  that  the  major  branches  of  this  ganglion  pass  to  the  body  of  the 
uterus.  A  small  part  of  the  uterine  nerves  originates  from  the  hypogastric 
plexus,  which  supplies  the  side  and  dorsal  surface  of  the  uterus.  From  the 
pelvic  brain  and  vesical  ganglion,  nerves  accompany  the  uterine  artery  along 
the  lateral  borders  of  the  uterus,  sending  branches  to  the  uterus  on  the  hori- 
zontal arteries,  and  to  the  oviducts  which,  by  union  with  the  ovarian  nerves, 
form  the  ovarian  ganglion.  From  the  ovarial  ganglion,  nerves  pass  to  the 
anterior  side  of  the  uterus,  to  the  inner  and  middle  parts  of  the  oviduct  and 
to  the  broad  ligaments. 

The  ligamentum  teres  uteri  is  composed  of  nonstriped  muscle  and  is  sup- 
plied by  both  the  uterine  and  ovarian  nerves.  The  uterus  is  supplied  in  its 
muscularis  by  an  extraordinary,  rich  network  of  nerves,  which  is  continued 
into  the  muscularis  vaginae.  The  uterine  mucosa  has  numerous  ganglia  dis- 
tributed in  its  substance.  The  nerve  endings  pass  to  the  epithelia  of  the  sin- 
gle organs.     The  small  capillaries  are  enclosed  in  a  network  of  nerves. 

IV.       GENERAL  VIEWS  OF  PAIN  IN  GYNECOLOGY. 

Pain  in  gynecology  is  generally  described  as  typical  in  character.  This 
is  observed  from  the  terms  which  writers  employ.  Some  designate  the  pain 
as  nongenuine,  others  as  hysteric,  and  again  as  illegitimate,  ideal  or  physical. 
Perhaps  with  more  accuracy  one  might  designate  the  pain  as  from  the  cortex 
of  the  cerebro-spinal  axis.  It  should  be  recognized  that  a  more  rational 
classification  of  pain  in  gynecology  is  demanded. 

Hysteria,  if  the  term  be  employed,  must  be  recognized  by  definite  stig- 
mata. It  is  true  in  gynecology  we  are  dealing  chiefly  with  the  subjective 
sensations  of  the  patient.  The  pain  appears  to  the  patient  as  immeasurably 
severe  and  terrible.  Frequently  the  only  standard  is  the  patient's  tears,  fears 
or  moans,  and  her  comparison  of  dragging,  tearing  or  boring.  We  can  to  some 
extent  estimate  colic  pains  of  hollow  organs  as  uterine  and  intestinal  condi- 
tions. But  it  is  remarkable  how  gynecologic  patients  bear  the  genuine  pain 
of  labor  and  other  colicky  pains  with  little  complaint  and  slight  fear  of  its 
repetition;  while  the  immeasurable  and  often  apparently  nongenuine  pain 
of  hyperesthesia  causes  exaggerated  and  bitter  complaints.  The  intensity  of 
pain  can  be  supposed  but  never  sharply  measured.  An  exudate  can  be  pal- 
pated, the  amount  of  blood  loss  judged,  the  growth  of  a  tumor  estimated, 
but  the  determination  of  pain  rests  alone  on  the  dogmatic  assertion  of  the 
patient.  It  is  a  physical  phenomenon.  As  Dr.  Lomer  states  in  his  excellent 
investigations,  pain  is  an  increase  of  touch  sensation,  and  has  a  psychical 
character.  Doubtless  the  sensory  periphery  apparatus  ends  first  in  the  skin 
(hyperesthesia  and  anesthesia),  and  second  in  the  mucosa  (hyperesthesia  and 
anesthesia). 


RELATION  OF  SPINAL  TO  SYMPATHETIC 


295 


The  chief  center  of  pain  for  the  periphery  apparatus  of  skin  or  mucosa 
lies  in  the  dorsal  sensory  ganglia  of  the  spinal  cord. 

Disease  in  either  the  spinal  sensory  ganglia  or  the  sensory  periphery, 
unbalances  the  nervous  system.  Analysis  and  clinical  observation  would 
indicate  that  the  hyperesthesia  and  anesthesia  are  of  central  (cerebro-spinal) 
origin.  Head,  of  England,  reported  some  ingenious  experiments,  in  which 
every  visceral  disease  is  announced  through  the  sympathetic  nerve  by  a  speci- 
fic zone  of  skin  tenderness.  The  center  of  the  sympathetic  fiber  lies  directly 
in  the  sensory  nerve.  If  a  sympathetic  irritation  arises  it  is  reflected  on  the 
tract  of  the  sensory  nerve  to  its  specific  skin  periphery.  The  result  is  a  spe- 
cific tender  skin  zone.  In  fact,  Head  allots  a  typical  sensory  skin  zone  for 
each  individual  viscus.  For  example,  there  is  a  specific  zone  of  skin  tender- 
ness for  a  stone  in  the  kidneys,  a  stone  in  the  gall  bladder,  or  a  diseased  uterus 
or  ovary.  However,  this  is  only  another  way  of  saying  that  visceral  irritation 
passes  to  the  spinal  cord,  and  after  reor- 
ganization, radiates  on  the  muscular  nerves 
of  the  abdomen  and  also  on  the  skin  nerves 
of  the  abdomen.  Irritation  of  the  periph- 
ery of  visceral,  muscular,  or  skin  nerves, 
affects  the  other  two  by  reflection.  In  any 
case,  the  process  of  transmission  of  pain 
from  periphery  to  center  is  a  complicated 
one.  The  variation  of  intensity  of  pain  is 
equally  shared  by  variation  of  its  quality  as 
boring,  sticking,  burning,  cutting,  tearing, 
dull  and  jumping  pain.  One  can  suppose 
an  organ  pain,  as  a  toothache,  an  earache, 
ovarian  pain,  uterine  and  intestinal  colic, 
tenesmus  of  urethra  or  rectum.  Organ 
pains  require  an  agent  or  irritation  to  start 
them,  and  are  not  a  quality  of  the  nerves  of 
the  viscus  itself. 

From  practical  gynecology,  pain  may  be  classified  as  follows,  viz.: 

1.  Traumatic  (wound)  pain,  the  irritation  of  sensory  nerves  from  exter- 
nal insults.  Frequent  examples  of  traumatic  pain  occur  in  the  urethral, 
vulval,  hymenial,  perineal,  and  anal  lacerations.  The  pain  is  acute,  but 
quickly  subsides.  However,  it  is  easily  revived  by  functionating  of  the 
organs,  or  secretions  flowing  on  the  wound.  Destruction  of  nerves,  as  from 
burns  or  chemicals,  has  the  most  intense  and  persistent  pain.  Patients  gen- 
erally describe  traumatic  (wound)  pain  as  burning  or  smarting.  An  ice  bag 
is  effectual  in  alleviating  such  pain. 

2.  Contractile  (colic)  pain,  the  irritation  of  the  sensory  nerves  through 
muscular  contraction.  It  is  vascular  spasm.  The  well  known  examples  of 
contractile  pain  (colic)  are  uterine  and  intestinal  colic,  the  over-filled  rectum, 
oviducts,  or  urinal  or  gall  bladder.  Vaginismus,  though  of  other  origin,  is  a 
typical  example.  This  pain  is  rhythmic  or  peristaltic.  It  rises  to  a  maxi- 
mum and  sinks  to  a  minimum.     It  is  described  as  an  ache. 


Fig.  70.  (Byron  Robinson.)  Rep- 
resents a  plan  of  a  dorsal  nerve. 
(Sp.  c.)  Spinal  cord.  [p.  b.)  Posterior 
branch,  (a.  b.)  Anterior  branch,  (g.) 
Ganglion  on  posterior  root.  (ram. 
com.)  Ramus  communicans.  (sy. 
gang.)  Sympathetic  ganglion,  (p.  c.) 
Posterior  cutaneous.  (a.  d.  or  a.  c.) 
Anterior  division.  (/.  c.)  Lateral  cu- 
taneous branch. 


296  THE  ABDOMINAL   AXD   PELVIC   BRAIN 

3.  Inflammatory  pain,  the  irritation  caused  by  trophic  changes  in  sensory 
nerves.  The  changes  are  produced  by  pressure  (exudation)  or  chemical 
effects  on  the  sensory  nerve  endings.  It  is  the  degenerative  disturbance  in 
the  sensory  nerve  area.  Its  conditions  are  calor,  rubor,  tumor, — dolor.  The 
pain,  though  complicated,  is  described  as  sticky,  cutting,  and  beating,  and  as 
a  rule  is  extraordinarily  painful. 

4.  Neuralgic  pain,  the  irritation  produced  by  changes  in  the  sensory 
nerve  itself  and  perhaps  its  ganglion.  Neuralgic  pain  is  characterized  by 
attacks  and  intermissions.  It  is  typically  observed  in  herpes  zoster  and 
herpes  vulvaris.  The  neuralgic  pain  is  described  as  lancinating  or  lightning- 
like in  character.  It  is  characteristic  for  neuralgic  pain  to  remain  limited  to 
a  definite  nerve  territory.  It  is  unilateral.  It  commonly  attacks  the  ilio- 
inguinal nerve  or  external  cutaneous,  also  the  pudendal  and  intercostal. 

5.  Hysterical  pain,  the  irritation  caused  by  disturbances  in  the  cerebro- 
spinal system.  This  pain  is  limited  to  no  organ  or  nerve  zone.  It  exists 
perhaps  equally  among  men,  women,  and  children.  Hysteria  has  nc  more 
to  do  with  the  uterus  than  with  the  liver  or  testicle.  It  is  not  a  gynecologic 
disease.  It  is  true,  gynecologic  subjects  possess  it,  but  often  from  devitalized 
power.  It  exists  independent  of  nerve  distribution.  It  is  not  influenced  by 
rest,  or  scarcely,  perhaps,  through  drugs.  The  fundamental  cause  of  hysteria 
is  heredity,  the  transmission  of  defects  or  a  neuropathic  condition.  The 
provocative  agent  of  hysteria  is  some  debilitating  effect,  mental  or  physical. 
Dr.  Lomer  insists  that  the  hyperesthetic  and  anesthetic  zones  of  the  skin  are 
geometrical  figures.  Hysteria  depends  on  psychical  alteration.  It  is  gen- 
erally described  as  burning  pain.  The  two  chief  therapeutic  agents  for  hyste- 
ria are  {ci)  suggestions  and  {b)  limited  galvanic  electricity.  Hyperesthesia 
may  perhaps  exist  in  any  viscus,  and  the  typical  characteristic  of  hysteria 
being  hyperesthesia  of  the  abdominal  skin,  that  attribute  could  be  found 
anywhere  on  the  skin  if  sought. 

Hysteria  distinguishes  itself  from  all  other  diseases  by  certain  stigmata. 
One  or  more  of  these  stigmata  must  be  present  to  diagnose  any  case  of  hys- 
teria.    The  stigmata  of  hysteria  are: 

1.  Hyperesthesia  of  the  skin,  which  consists  in  exaltation  of  the  sensory 
periphery.  These  areas,  hystero-genetic  zones,  are  especially  found  on  the 
skin  of  the  abdomen.  The}'  are  painful  or  over-sensitive  on  touch.  The 
patient  is  often  deceived  by  thinking  the  pain  in  the  skin  of  the  groin  refers 
to  the  ovary.  Hystero-genetic  zones  or  hyperesthetic  areas  occur  all  over 
the  body,  but  in  the  sexual  region  they  are  apt  to  be  more  typical  on  account 
of  the  patient's  active  attention.  The  skin  over  the  ovary  or  the  kidney  may 
be  so  hyperesthetic  and  tender  that  grave  kidney  disease  may  be  suspected. 
The  skin  over  any  abdominal  viscus  may  be  so  tender  that  touching  it  induces 
the  patient  to  scream,  while  the  viscus  itself  is  quite  healthy.  Hyperesthesia 
exists  chiefly  on  the  right  side.  Pinching  or  pricking  the  skin  enables  one 
to  discern  the  zones  of  hyperesthesia. 

Hyperesthesia  of  the  skin  on  the  abdomen  may  exist  with  or  without 
healthy  genitals.     Of  course  the  hyperesthesia  of  the  skin  is  more  liable  to 


RELATION    OF    CEREBROSPINAL    TO    SYMPATHETIC 


29' 


exist  with  diseased  genitals,  as  the  genitals  may  be  the  provocative  or  debil- 
itating agent  inducing  the  hysteria.  The  patients  who  are  disturbed  by 
crawling  sensations  on  the  skin,  as  of  snakes  and  ants,  have  hyperesthesia 
and  hence  have  hysteria.  Hyperesthetic  spots  anywhere  on  the  body  consti- 
tute one  of  the  stigmata  of  hysteria.  I  observed  hyperesthetic  spots  year 
after  year  on  a  woman's  back.  The  hyperesthesia  of  the  skin  may  change  its 
location.  The  frequency  of  skin  hyperesthesia  in  the  gynecologic  clinic 
induces  me  to  believe  in  the  wide  distribu- 
tion of  hysteria,   independent  of  gynecology. 

2.  Anesthesia  of  the  skin  is  also  another 
stigma  of  hysteria.  This  is  not  so  frequent  in 
the  clinic.  The  patient  complains  of  the  skin 
being  numb  and  without  feeling.  It  is  found, 
perhaps,  most  frequently  on  the  skin  of  the 
abdomen.  Anesthesia  exists  chiefly  on  the 
left  side  of  the  body. 

3.  Anesthesia  of  the  mucosa  is  one  of 
the  stigmata  of  hysteria  seldom  absent.  The 
test  is  easily  made  by  taking  a  pin  with  a 
small  glass  head  and  rubbing  it  over  the  eye- 
ball. If  the  conjunctiva  bulbi  is  anesthetic, 
one  can  rub  the  pinhead  over  the  eyeball 
without  a  wink  or  flinch  from  the  patient. 
Normally  the  conjunctiva  is  very  sensitive, 
and  to  touch  it  produces  reflex  actions,  tears 
and  pain.  Nearly  always  in  the  hysteria  the 
rubbing  of  the  pinhead  on  the  eyeball  pro- 
duces no  reflexes,  no  tears,  no  pain.  Of  course 
there  are  many  grades  of  anesthesia  of  the 
conjunctiva  bulbi.  The  corneal  anesthesia  is 
the  least  frequent.  The  anesthesia  of  the 
throat  is  tested  by  a  lead  pencil  or  sound. 
On  rubbing  the  mucosa  of  the  throat,  no  reflex 
nor  pain  arises.  As  Windscheid  remarks, 
however,  the  diagnosis  of  hysteria  should  not 
be  made  from  anesthesia  of  the  throat  alone, 
as  in  healthy  subjects  the  mucosa  of  the  throat 
may  show  various  degrees  of  anesthesia. 

4.  Hyperesthesia  of  the  mucosa  must  be  remembered  among  the  stig- 
mata of  hysteria,  though  infrequent.  The  persistent  feeling  of  animals 
crawling  in  the  tractus  intestinalis  (abdomen)  is  no  doubt  a  symptom  of  an 
over-tender  mucous  membrane.  The  sudden  expulsion  of  unchanged  foods 
from  some  stomachs  immediately  after  eating  is  no  doubt  due  to  hyperesthesia 
(non-toleration)  of  the  gastric  mucosa. 

Hyperesthesia  of  the  viscera  is  one  of  the  known  stigmata  of  hysteria. 
Perhaps  visceral  hyperesthesia  exists  the  most  frequently  in  the  ovary.      In 


DIAGRAM  OF  LUMBAR  AND 

PELVIC  PLEXUSES 

(QUAIN) 

Fig.  71.  (DXII.)  Last  dorsal. 
(IS.)  First  sacral.  (8)  Pudic. 
(Sc.)  Sciatic.     (V.)  Lumbosacral. 


298  THE  ABDOMINAL   AXD   PELVIC  BRA  IS 

such  cases  the  ovary  is  hypersensitive  to  touch,  yet  normal  in  size  and  posi- 
tion, perfectly  mobile,  with  no  peritoneal  adhesions  or  fever.  Castration 
does  not  affect  the  pain  unless  it  exacerbates  it.  The  irritable  uterus  of  the 
old  doctors  is  undoubtedly  of  hysteric  nature.  To  show  that  such  cases  are 
hysteric,  the  uterus,  oviducts  and  ovaries  have  been  removed,  but  the  pain 
persists  just  as  before  the  operation.  I  once  operated  on  a  hyperesthetic 
kidney  in  which  I  suspected  stone,  but  no  stone  existed  and  the  pain  persisted 
as  before  the  operation.  Hyperesthesia  of  the  cord  and  testicle  frequently 
exists.  Vaginismus  is  perhaps  as  typically  hysterical  as  any  example  of 
the  viscera.  Vaginismus  may  be  called  up  by  the  thought  of  touching  the 
vulva.  It  is  chiefly  of  psychical  origin  and  occurs  in  neuropathic  individu- 
als. It  is  common  to  note  hyperesthesia  of  the  orificium  vaginae,  and  an 
exacerbation  of  this  leads  to  various  grades  of  vaginismus. 

The  hymen  has  been  extirpated  in  vaginismus,  but  without  good  effect. 
There  can  be  little  doubt  that  hysteric  bladders  frequently  arise  in  the  prac- 
tice. I  once  treated  a  patient  two  years  for  a  hysteric  bladder.  Drugs  had 
little  or  no  effect.  Rest  in  bed  made  no  change.  Suggestion  was  the  best 
treatment.  Urine  was  normal.  It  was  so-called  irritable  bladder,  hysteria. 
The  patients  with  irritable  or  hysteric  uterus  are  the  ones  who  prepare  for 
the  child's  advent  by  making  the  clothing,  and  sending  for  the  midwife. 
They  suffer  from  labor  pains,  and  finally  call  the  obstetrician  when  labor 
does  not  complete  itself,  only  to  find  that  the  patient  is  not  even  pregnant. 
She  is  misled  by  her  irritable,  hyperesthetic,  hysteric  uterus.  The  abdominal 
cramps  and  colic  of  certain  neuropathic  patients  are  doubtless  due  to  visceral 
hyperesthesia  or  hysteria. 

5.  The  muscular  stigma  of  hysteria  is  quite  common.  It  consists  in  the 
paresis  or  paralysis  of  one  or  more  muscles,  or  it  consists  in  exacerbation  of 
contractions  of  one  or  more  muscles.  When  the  tongue  suddenly  ceases  to 
act,  with  subsequent  normal  action,  it  is  quite  sure  to  be  hysterical  in  nature. 
Globus  hystericus  is  simply  exacerbated  activity  of  the  esophageal  and  gas- 
tric muscles.  Hysteric  knee  is  a  spasmodic  contraction  of  the  muscles  sup- 
plying it.  The  lost  voice  is  frequently  of  hysteric  nature,  due  to  disturbances 
of  laryngeal  muscles.  The  "lumps"  or  tumors  in  the  abdomen  of  many 
patients  are  simply  the  contractions  of  certain  abdominal  muscles,  frequently 
accompanied  by  hyperesthesia  of  the  skin  over  them.  The  patient  complains 
of  a  tender  tumor,  and  the  diaphragm  or  groups  of  muscles  become  spas- 
modic. 

6.  Another  stigma  of  hysteria  is  psychosis.  It  is  perverted  mental 
action.  Hysteria  is  chiefly  manifest  to  the  gynecologist  as  a  psychical  dis- 
ease. It  is  a  part  of  a  neurosis,  very  changeable,  and  ever  presenting  new 
scenes.  It  doubtless  rests  on  a  psycho-pathic  construction.  The  psychosis 
rests  also  no  doubt  on  a  defective  system.  An  irritable  weakness  exists  in 
the  nervous  system.  The  central  or  peripheral  nervous  system  is  defective 
The  hysteric  condition  is  especially  susceptible  to  influence  or  suggestibility. 

7.  Exaltation  or  diminution  of  the  special  senses  is  also  a  stigma,  as 
blindness  or  exalted  hearing.     Hereditv  or  congenital  defect  is  a  large  factor. 


RELATION    OF    CEREBROSPINAL    TO    SYMPATHETIC 

Whatever  debilitates  the  nervous  system,  local  or  general,  invites  hysteria 
as  a  provocative  agent.  It  should  be  remembered  that  genital  disease 
(infectious)  is  debilitating,  and  hence  is  followed  frequently  by  hysteria. 
Sexual  diseases  (in  man  or  woman)  no  doubt  play  a  vast  role  in  hysteria. 
They  are  productive  agents.  Of  special  interest  are  the  hyperesthetic  zones 
of  the  abdomen;  i.  e.,  the  periphery  of  the  sensory  nerves  of  the  abdomen. 

8.  The  sensory  periphery  area  of  the  ilio-inguinal,  ilio-hypogastric  and 
that  of  the  eight  lower  intercostals,  become  exalted  in  sensation.  Hysteria 
is  a  disease   of  symptoms.     There  are  two  theories  of  hysteria  extant  at 


ABDOMINAL  BRAIN 

Fig.  72.     This  illustration  I  dissected  under  alcohol.     It  represents  fairly  accurately  the 
cerebrum  abdominale  in  the  general  subject. 


present,  viz.:  (a)  It  is  a  psychosis,  a  mental  disturbance.  Its  seat  is  the 
cerebral  cortex,  {b)  It  is  a  neurosis  or  a  psycho-neurosis.  It  is  not  limited 
to  the  cerebral  cortex,  but  is  a  disease  of  the  whole  nervous  system.  It  is  a 
disease  of  rapidly  changing  panorama. 

The  treatment  of  hysteria  must  be  rational,  systematic,  prolonged,  and 
continuously  suggestive.  Drain  the  skin  by  salt  rubs,  massage ;  drain  the 
kidneys  by  ample  drinking  of  fluids ;  drain  the  bowels  by  proper  diet,  sufficient 
laxation,  and  fluid  and  regular  evacuations.  Tonics  to  improve  digestion, 
drugs  to  act  on  the  senses,  especially  the  olfactory;  electricity  to  act  on  the 


300  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

cerebral  cortex,  and  continual  suggestions  with  firm  discipline.  Above  all 
ideas  of  hysteria  or  neurasthenia  must  stand  the  thought  that  all  operations 
to  cure  them  are  to  be  abandoned. 

In  gynecologic  patients  there  is  a  triumvirate  of  pain — back,  head,  and 
stomach.     It  represents  three  groups  of  painful  localities. 

1.  The  lumbo-sacral  region  is  the  seat  of  the  most  prevalent  and  per- 
sistent. It  is  the  central  station  which  interprets  the  pain  of  the  pelvic 
sensory  periphery.  Almost  every  gynecologic  affection  creates  lumbo-sacral 
symptoms,  whether  it  be  dislocation,  inflammation,  contractile  pain,  sacro- 
pubic  hernia,  mechanical  pressure  or  malignant  growths.  In  short,  the 
lumbo-sacral  region  is  the  sensorium  of  gynecology  of  the  pelvis.  The  spin- 
al ganglion  must  act  as  local  substitute  for  the  brain.  The  explanation  of 
this  lies  in  the  kind  of  nerves:  visceral,  peritoneal,  muscular,  and  cutaneous, 
which  report  to  the  lumbo-sacral  cord. 

The  visceral  nerves  are  the  second,  third  and  fourth  sacral  and  the  sym- 
pathetic—all transmit  reflexes  to  the  lumbo-sacral  cord  from  irritation  of  the 
genitals. 

The  peritoneal  nerves  are  branches  of  the  ilio-inguinal,the  ilio-hypogas- 
tric,  and  the  seven  lower  intercostals,  which  transmit  pelvic  peripheral 
irritation  to  the  lumbo-sacral  cord. 

The  muscular  nerves  of  the  lumbo-sacral  plexus  and  also  those  of  the 
muscular  seven  lower  intercostals  transmit  disturbances  to  the  lumbo-sacral 
cord. 

The  cutaneous  branches  of  the  lumbo-sacral  plexuses,  especially  the 
pudic,  the  pudendal,  the  ilio-inguinal,  ilio-hypogastric  and  seven  lower  inter- 
costal cutaneous  branches,  report  irritation  to  the  sacro-lumbar  cord. 

The  irritation  of  the  periphery  of  any  of  the  three  great  branches  of  the 
lumbo-sacral  cord,  viz.,  cutaneous,  muscular  or  viscero-peritoneal,  disturbs 
the  balance  of  the  other  two.  Irritation  of  the  visceral  sensory  periphery 
unbalances  the  sensory  periphery  of  the  muscular  and  cutaneous  nerves. 
The  spinal  ganglia  are  reorganizers  and  transmit  all  reports  to  every 
periphery.  This  is  a  cue  to  therapeutic  agents,  e.  g. .  cutaneous  irritation  is 
carried  to  the  spinal  cord  and  reflected  on  the  muscular  and  visceral  branches, 
stimulating  both. 

2.  Gynecologic  disease  refers  a  group  of  pain  to  the  stomach. 

3.  Another  group  is  referred  to  the  head.  Laparotomy  wounds  seldom 
or  never  give  rise  to  pain  if  union  is  by  first  intention.  The  lower  angle  of 
the  wound  is  sometimes  painful  under  pressure,  but  it  is  undoubtedly  due  to 
suppuration  from  close  proximity  to  the  region  of  the  hair.  Dorsal  muscles 
are  inclined  to  rheumatism,  while  those  of  the  abdomen  are  not ;  hence,  more 
accurate  judgment  arises  as  to  painful  abdominal  incisions.  Special  atten- 
tion should  be  paid  to  hyperesthesia  of  the  abdominal  skin  by  the  gynecologist 
and  surgeon,  as  it  may  exist  without  visceral  disease,  and  hence  may  be  non- 
surgical. So-called  "irritable"  organs  with  no  visible  or  palpable  anatomic 
change,  should  be  referred  to  hysteria. 

When  a  rational  treatment  is  systematically  carried  on  against  painful 


RELATION    OF    CEREBROSPINAL    TO    SYMPATHETIC      301 

local  disturbance,  without  effect,  the  probability  is  that  it  is  a  hysteric  hyper- 
esthesia. The  excessive  vomiting  of  pregnancy  often  has  a  hysteric  base  — 
hyperesthesia  of  the  gastric  mucosa.  In  the  same  hysteric  category  must 
often  be  numbered,  coccygodynia,  coxalgia,  irritable  bladder,  breast,  and 
uterus,  vaginismus,  pruritus,  dysmenorrhea,  and  a  sense  of  lumbo-sacral 
symptoms.  A  knowledge  of  the  above  factors  is  particularly  valuable  to  the 
operator  as  the  sweeping  removal  of  organs  for  neurosis  or  hyperesthesia  is 
criminal.  Remember  that  morbid  sensibility  lies  chiefly  in  the  skin,  and  the 
patient  will  complain  more  of  a  skin  pinch  than  a  deep-seated  trauma. 
What  the  hysteric  coxalgia  or  hysteric  knee  is  to  the  surgeon,  so  is  the 
hyperesthesia  of  the  abdomen  to  the  gynecologist.  The  puzzle  of  each 
solves  itself  under  the  analysis  for  stigmata. 


V 


CHAPTER  XXIV. 

HYPERESTHESIA  OF  THE  SYMPATHETIC. 

"Surmises  are  not  facts.     Suspicions  which  may  be  unjust  need  not  be  stated." 
— Abraham  Lincoln. 

"Men  are  merriest  when  they  are  from  home." — Shakespeare. 

1.  Hyperesthesia  of  the  abdominal  brain  (Neuralgia  Celiaca)  consists  of  a 
sudden  violent  pain  in  the  region  of  the  stomach.  The  pain  is  accompanied 
by  a  sense  of  fainting  and  impending  anxious  dread.  It  manifests  itself, 
objectively,  chiefly  in  the  character  of  the  circulation  and  in  the  facial 
appearance.  The  skin  is  pale,  the  extremities  cold,  the  muscles  assume 
vigorous  contractions,  especially  over  the  abdomen,  and  the  heart  beats  under 
tension  and  may  intermit.  The  abdominal  muscles  are  put  on  a  stretch. 
Some  patients  are  occasionally  relieved  by  pressure  on  the  stomach.  From 
the  intimate  and  close  anatomical  connection  of  the  abdominal  brain  with 
all  the  abdominal  viscera,  and  also  the  thoracic  viscera,  various  other  symp- 
toms of  a  similar  character  to  neuralgia  celiaca  may  and  do  arise,  as  disturb- 
ance in  the  action  of  the  heart  and  of  the  gastro-intestinal  tract.  The  attacks 
are  irregular,  periodical,  uncertain  in  time  and  intensity.  The  attack  may 
last  a  few  minutes  to  half  an  hour.  The  attack  may  disappear  slowly  or 
under  a  crisis  of  perspiration,  emission  of  gas,  vomiting  or  copious  urination, 
leaving  the  patient  apparently  very  exhausted.  The  peculiar  characteris- 
tics of  the  attacks  in  the  abdominal  brain  determine  neuralgia  celiaca  from 
inflammatory  processes  of  the  stomach. 

The  most  typical  neuralgia  celiaca  coming  under  my  notice  was  (1890) 
that  of  a  man  about  40,  a  real  estate  dealer,  in  whom  it  had  persisted  for 
perhaps  ten  years.  I  could  discover  no  gall-bladder,  heart  or  ureteral  trouble, 
and  no  stomach  lesion.  He  was  attacked,  irregularly,  however,  depending 
on  over-exertion,  several  times  a  year.  When  attacked  he  felt  that  impend- 
ing death  was  at  hand.  He  screamed  between  paroxysms  and  would  fall  on 
the  floor,  rolling  in  agony  for  a  half  or  three-quarters  of  an  hour.  He 
anticipated  the  terrific  attacks  by  preparing  for  them  with  great  care  of  his 
health.  He  would  be  very  quiet  for  one  or  two  days  subsequent  to  the  attacks ; 
otherwise  he  was  quite  healthy.     I  soon  lost  sight  of  him. 

The  second  most  typical  case  of  neuralgia  celiaca  in  my  practice  was  that 
of  a  woman  (1883)  about  28.  She  had  very  severe  and  frequent  attacks  which 
lasted  some  fifteen  minutes;  seemed  to  have  terrible  dread  and  anxiety,  a  wiry, 
small  pulse,  rigid  abdominal  muscles  and  varying  pupils  during  the  attack. 
She  appeared  greatly  relieved  by  pressure  directly  on  the  stomach  during  the 
attack.  She  recovered  with  much  exhaustion  and  relaxation;  otherwise  she 
appeared  well.     She  died  of  rectal  carcinoma  some  twelve  years  later.     Neu- 

302 


HYPERESTHESIA  OF  THE  NERVUS  VASOMOTOR! 


303 


ralgia  celiaca  may  exist  in  very  various  degrees  of  intensity  and  duration. 
In  some  very  severe  attacks  it  would  seem  from  appearances  and  the  patient's 
report  that  the  suffering  was  more  profound  than  an  ordinary  death.  The 
chief  valuable  treatment  consists  in  securing  active  secretion  of  the  skin  and 
kidneys  with  free  bowel  evacuation.     General  tone  is  secured  by  tonics  and 


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CORROSION   ANATOMY 

Fig.  73.  Corrosion  anatomy  of  the  ductus  pancreaticus  and  part  of  the  ductus  bilis  in 
two  subjects.  The  illustration  suggests  the  quantity  of  nerves  to  control  the  caliber  of  the 
numerous  ducts. 


304  THE  ABDOMINAL  AND  PELVIC  BRAIN 

wholesome  food;  even  temperature  and  quiet  life  tells  the  rest  of  the  story. 
The  treatment  during  the  attacks  is  purely  expectant — sedative  and  stimulant. 
Vigorous  baths  and  wholesome  suggestions  are  valuable.  There  is  often  more 
in  the  advice  given  with  the  medicine  than  in  the  medicine  itself. 

Neuralgia  celiaca  resembles  angina  pectoris  more  than  any  other  neuralgia 
of  the  sympathetic  ganglia.  It  requires  judgment  and  skill  to  diagnose  it 
from  some  forms  of  angina  pectoris,  and  its  treatment  is  equally  as  doubtful. 
Of  course,  it  is  physical  lesions  which  we  suspect  in  neuralgia  of  the  abdominal 
brain,  as  the  physician  cannot  consent  to  the  view  that  a  machine  (the  sym- 
pathetic ganglia)  may  go  wrong  without  its  becoming  structurally  defective 
somewhere.  Electricity,  massage  and  cold  packing  are  quite  effective.  Some 
writers  consider  this  subject  under  the  terms  gastralgia  or  gastrodynia.  But 
under  whatever  term  it  may  be  discussed,  the  peculiar  sense  of  fainting,  the 
anxiety,  dread  and  feeling  of  impending  destruction  of  the  very  center  of  life 
itself  during  the  attack,  and  especially  its  action  on  the  vascular  system, 
sufficiently  characterize  it  as  neuralgia  of  the  abdominal  brain — neuralgia 
celiaca.     The  diseases  of  the  vagus  manifest  themselves  otherwise. 

2.  Hyperesthesia  of  the  mesenteric  plexus  (Neuralgia  Mesenterica, 
enteralgia,  enterodynia  or  colic)  signifies  pain  in  the  region  of  the  bowel  sup- 
plied by  the  nerves  accompanying  the  superior  mesenteric  artery,  i.  e.,  the 
region  of  the  small  intestine  and  the  large  bowel  from  the  appendix  to  the 
splenic  flexure.  The  pain  is  irregular,  dragging,  sickening,  pinching,  boring, 
accompanied  by  a  sense  of  tenderness  over  the  abdomen.  The  pain  shifts  from 
one  segment  of  the  bowel  to  another;  is  generally  located  below  the  umbilicus; 
alternates  with  intervals  of  cessation  and  does  not  generally  begin  suddenly,  but 
gradually  ascends  to  a  maximum.  It  may  be  so  severe  as  to  induce  a  sense  of 
faintness.  Some  patients  assume  positions  to  ease  the  pain,  as  pressing  the 
hands  on  the  abdomen,  bending  the  thighs  on  the  abdomen  ;  some  are  very  rest- 
less under  the  attacks.  The  abdomen  may  be  distended  with  gas  or  retracted. 
The  attack  may  pass  off  with  crisis  of  the  passage  of  gas,  vomiting,  sweating, 
profuse  urination.  The  attacks  last  from  a  few  minutes  to  several  hours. 
Some  patients  are  subject  to  these  attacks  for  some  months  in  succession. 
The  patient  may  have  intervals  of  entire  freedom  from  the  attacks.  Yet 
the  general  observation  is  that  constipation  characterizes  patients  with  mes- 
enteric neuralgia.  It  is  understood  here  that  the  pain  does  not  arise  from  a 
recognizable,  demonstrable  organic  lesion,  as  ulceration  of  the  mucosa, 
lesion  of  the  bowel  wall  or  serosa,  but  from  a  nervous  base.  The  pain  may 
be  merely  short,  sharp  twinges,  which  some  neurotic  women  describe  year 
in  and  }-ear  out.  The  clinical  picture  of  the  disease  offers  manifold  variations. 
Some  patients  have  meteorism,  pain  about  the  navel,  rumbling  (borborygmus) 
in  the  bowels.  Some  have  gurgling  in  the  intestines,  which  appears  to  be  due 
to  a  sudden  irregular  contraction  of  the  bowel  which  rapidly  forces  the  con- 
tents onward.  In  fact,  patients  with  neuralgia  mesenterica  often  possess  a 
catalogue  of  other  neurotic  manifestations.  Nausea,  dysuria  and  tenesmus 
may  be  present.  The  chief  accompaniment  of  this  disease  is  perhaps 
constipation.  However,  the  pains  of  mesenteric  neuralgia  should  not  be 
confounded  with  those  of  intestinal  colic. 


NEURALGIA   OF  THE  NERVUS  VASOMOTORIUS  305 

The  first  author  of  celebrity  who  wrote  with  clear  views  on  the  distinction 
between  neuralgia  mesenterica  and  intestinal  colic  was  Thomas  Willis  (1622- 
1675),  an  English  physician  well  remembered  by  anatomists  in  the  "Circle  of 
Willis,"  in  numbering  the  cranial  nerves  and  in  the  nerve  of  Willis  (the  spinal 
accessory).  Willis  observed  over  230  years  ago  that  mesenteric  neuralgia  was 
not  a  disease,  but  merely  a  symptom.  He  said  it  should  be  distinguished  from 
the  vulgar  term,  "the  gripes"  (intestinal  colic).  Willis  also  noted  what  others 
see  today,  that  the  more  violent  attacks  of  mesenteric  neuralgia  generally  have 
regular  periods  and  follow  the  changes  of  the  weather  and  the  season;  when 
once  excited  they  yield  with  difficulty  to  remedies,  do  not  pass  off  quickly, 
and  may  persist  for  weeks  with  great  violence.  In  regard  to  the  seat  of  pain, 
it  may  be  noted  that  in  the  same  individual  it  generally  repeats  itself  in  the  same 
region.  The  nerve  tract  sufficiently  defective  to  harbor  a  neuralgia  tends  to 
retain  the  defect  throughout  life.  It  may  be  remembered  that  the  superior 
mesenteric  nerve  supplies  over  twenty  feet  of  small  and  nearly  three  feet  of 
large  intestine — a  vast  area — and  besides,  the  small  intestine  shifts  very  much 
daily;  hence,  the  pains  of  mesenteric  neuralgia  may  be  in  the  lumbar, 
umbilical  and  hypogastric  regions.  If  the  pain  occurs  at  the  pit  of  the  stomach, 
it  is  likely  located  in  the  transverse  colon. 

The  clinical  picture  of  mesenteric  neuralgia  is  so  manifold  in  its  aspect 
that  it  requires  the  best  heads  and  the  finest  skill  to  unravel  the  complicated 
symptoms.  The  differential  diagnosis  is  difficult.  In  certain  cases  where  the 
symptoms  lessen  after  the  evacuation  of  peculiarly  formed  rolls  of  mucus  there 
is  a  mixed  neorosis. 

Again,  the  mesenteric  neuralgia,  while  it  exists,  may  be  complicated  by 
attacks  of  asthma,  nausea,  dysuria,  hysteria  or  other  nervous  affections,  to 
which  subjects  afflicted  with  mesenteric  neuralgia  are  prone.  In  cases  of 
mesenteric  neuralgia,  certain  regions  of  the  abdominal  skin  may  show  hyper- 
esthesia from  the  connection  shown  to  exist  between  the  viscera  and  the 
abdominal  skin.  Mr.  Head,  of  London,  in  "Brain,"  1894,  demonstrated  the 
close  relation  existing  between  the  nerves  of  the  abdominal  viscera  and  the 
nerves  of  certain  skin  areas.  Hence,  in  cases  of  mesenteric  neuralgia  hyper- 
esthetic  skin  areas  on  the  abdomen  may  be  expected.  In  the  incipiency  it 
may  be  difficult  to  differentiate  a  beginning  peritonitis  from  mesenteric 
neuralgia.  But  of  worth  in  such  a  diagnosis  as  peritonitis  are  temperature, 
pain  on  pressure  on  the  abdomen,  general  pain  and  increase  of  pain  by  deep 
pressure  on  the  abdomen.  With  time  the  meteorism,  singultus  and  exudate 
become  more  evident  in  peritonitis.  In  gallstone  colic  tenderness  on  pressure 
arises  and  is  localized.  Icterus  may  follow  to  aid.  Renal  colic  is  differen- 
tiated from  mesenteric  neuralgia  by  its  being  localized  in  the  region  of  the 
kidney,  by  its  continual  radiation  along  the  ureters  toward  the  bladder  and 
testicles,  by  the  severe,  dragging  character  of  the  pain,  and  by  the  occasional 
expulsion  of  a  calculus;  yet  renal  colic  in  some  cases  may  so  simulate  mes- 
enteric neuralgia  that  differential  diagnosis  is  very  difficult,  if  not  impossible. 
This  might  occur  when  the  renal  irritation  flashes  to  the  abdominal  brain, 
becomes  reorganized  and  radiates  along  the  vast  area  of  the  superior  mesen- 
20 


306  THE  ABDOMINAL   AND   PELVIC  BRAIN 

teric  nerve.  An  ulcer  in  the  bowel  shows  constant  localized  pain  on  pressure. 
The  patient's  history,  the  omission  of  the  characteristic  periodic  attacks,  the 
formation  of  the  stools,  aid  in  diagnosing  ulcer  of  the  intestines.  It  may  be 
impossible  to  make  a  differential  diagnosis  in  the  incipient  stage  of  the 
disease. 

The  most  typical  species  of  mesenteric  neuralgia  known  to  the  writer  is 
lead  colic,  colica  saturnina.  Lead  colic  is  preceded  by  a  stage  of  constipa- 
tion accompanied  by  oppressive  pains  in  the  abdomen,  chiefly  about  the 
umbilicus.  Nausea,  eructations,  destroy  the  appetite.  Pinching,  twisting  and 
drawing  pains  occur  with  different  duration  and  intensity.  The  pains  are 
often  persistently  localized,  do  not  frequently  shift,  occur  in  paroxysms. 
The  pains  of  lead  colic,  mesenteric  neuralgia,  are  apt  to  arise  to  the  highest 
pitch  at  night  and  when  they  lessen  are  apt  to  leave  annoying  sensations, 
allowing  little  rest  during  the  intervals  of  paroxysms.  The  diagnosis  is  aided 
by  the  patient's  occupation,  history  association,  condition  and  state  of  climate. 
Arthritis,  rheumatism  and  malaria  induce  neuralgia. 

Having  established  the  diagnosis  of  mesenteric  neuralgia,  the  treatment 
will  refer  to  a  certain  extent  to  the  etiology.  Older  practitioners  relied  too 
much  on  evacuation  and  opium.  Modern  practice  attempts  to  correct  the 
malnutrition. 

The  first  symptom  of  significance  in  mesenteric  neuralgia  is  pain.  The 
second  symptom  of  importance  is  constipation.  Both  symptoms  demand 
vigorous  attention.  The  treatment  will  first  consist  in  attempting  to  estab- 
lish the  etiology  of  the  mesenteric  neuralgia.  Is  it  due  to  dietetic  defects, 
spirituous  liquors,  narcotics,  intestinal  contents,  coprostasis,  colica  flatulenta, 
animal  parasites,  metallic  poisoning,  or  catching  cold?  Or  again,  is  the  neu- 
ralgia due  to  general  nervous  affections,  as  neurasthenia,  to  an  exalted  irrita- 
bility of  the  bowel,  nerves  and  ganglia?  Is  it  caused  by  hysteria  or  locomotor 
ataxia?  Or  is  the  mesenteric  neuralgia  induced  by  some  diseased  abdominal 
viscus  reflecting  its  irritation  to  the  abdominal  brain,  whence  reorganized  it 
is  flashed  over  the  vast  area  of  the  superior  mesenteric  nerve,  rippling  the 
bowel  in  whole  or  in  segments;  An  investigation  of  the  above  considerations 
will  influence  the  treatment. 

First,  the  pain,  real  or  pretended,  will  demand  attention.  Opium  should 
be  avoided  if  possible.  Valerian,  asafetida,  i.  e.,  drugs  with  effect  on  the 
sense  of  smell,  influence  favorably,  but  perhaps  there  is  more  in  the  sugges- 
tion or  advice  which  accompanies  the  drug  than  in  the  drug  itself.  I  have 
observed  better  results  from  hot,  moist  poultices  (corn  meal),  making  the 
poultice  a  foot  square  and  three  to  six  inches  thick  and  applying  it  over  the 
abdomen.  Cold  packing  of  the  abdomen  in  heavy,  wet  towels  often  does 
well.  Electricity  has  good  moral  and  physical  effects.  A  hypodermic  of 
morphine,  1-16  of  a  grain,  is  effective.  However,  we  must  admit  that  a  good 
dose  of  opium,  e.  g.,  Yz  to  1  grain,  works  wonders  for  a  time  in  mesenteric 
neuralgia.  The  bromides  are  slow  but  effective  ■  however,  they  generally 
disturb  digestion.  Potassium  bromide  should  be  avoided,  as  it  irritates 
mucosa  and  skin,    frequently  calling  up  rashes;  20  to  30  grains  of  sodium 


NEURALGIA   OF  THE  NERVUS  VASOMOTORIUS 


307 


bromide    will    produce  a  quiet  nervous  system,   especially    inducing  restful 
nights  and  quiet  sleep. 

The  pain  of  mesenteric  neuralgia  being  disposed  of,  the  more  important 
subject  of  the  curative  treatment  should  be  carefully  considered.  The  most 
important  symptom  after  the  pain  is  that  of  constipation.  The  bowels  are 
indolent  and  are  affected  but  slowly,  even  by  active  purgatives.  The  evacua- 
tions are  scanty  and  difficult  to  perform.  The  feces  are  dry,  globular  in  shape 
and  brittle.     The  patients  are  distressed  by  fruitless  strainings.     It  is  useless 


CORROSION  ANATOMY 

Fig.  74.     Corrosion   anatomy   of  the   kidney,   presenting   ureteral   pelvis,  calyces  and 
arteria  renalis,  suggesting  the  quantity  of  nerves  required  to  control  these  canals. 


to  attempt  to  cure  such  patients  without  a  strict  and  rigid  regimen.  In  the 
first  place,  such  patients  will  not  drink  sufficiently;  and,  secondly,  they  lack 
a  regular  hour  for  evacuation.  I  have  treated  scores  of  patients  successfully 
for  the  constipated  habit  by  directing  that  a  large  tumblerful  of  water,  with 
magnesium  sulphate,  half  of  a  dram  to  a  dram  dissolved  in  it,  be  drank  every 
night.  Also,  that  the  patient  be  directed  to  go  to  stool  every  morning  after 
breakfast,  i.  e.,  after  the  hot  coffee  is  drank,  which  aids  peristalsis.  Direc- 
tion should  be  given  to  eat  food  which  leaves  a  large  bulk  of  residue,  as  oat- 
meal,  cornmeal,   and   graham    bread.       This   residual    bulk    stimulates  the 


308    ,  THE  ABDOMINAL   AXD   PELVIC  BRAIN 

intestines  to  active  peristalsis  by  contact  in  every  successive  segment.  Daily 
passages  of  the  bowel  and  electricity  aid  to  rouse  the  indolent  digestive  tract 
to  normal  activity.  The  constant  use  of  a  very  small  pill  of  aloin,  belladonna 
and  strychnine  is  very  effective.  Colonic  flushings  two  to  four  times  weekly, 
salt  water  and  friction  baths,  aid  nature  in  restoring  lost  tone.  Change  of 
environment,  climate,  a  sea  voyage,  but,  perhaps  better,  long  daily  walks, 
are  beneficial.     Horseback  and  bicycle  riding  are  helpful. 

The  course  of  mesenteric  neuralgia  as  regards  life  is  favorable;  the 
attacks,  which  vary  very  much  as  regards  intensity,  endure  from  one  to  sev- 
eral hours.  Neuralgias  arise  in  the  sympathetic.  Collins  demonstrated  that 
the  arteries  of  the  abdominal  viscera  were  possessed  of  great  sensibility  in 
which  the  arteries  of  other  parts  were  wanting.  It  is  likely  that  the  nerves 
accompanying  the  mesenteric  artery  participate  in  the  reflex  irritation,  induc- 
ing the  neuralgia. 

Hyperesthesia  of  the  hypogastric  plexus  consists  of  irregular,  periodic 
pains  radiating  from  the  abdomen  to  the  genitals,  bladder  and  down  the 
thighs  (including  the  inferior  mesenteric  plexus),  and  in  the  rectum.  The 
hypogastric  plexus  passes  from  the  abdominal  brain  along  the  aorta,  common 
iliacs,  and  from  the  bifurcation  of  the  aorta  two  large  strands  pass  on  to 
complete  the  pelvic  brain  or  cervical  uterine  ganglia.  In  the  female  the 
hypogastric  plexus  chiefly  supplies  the  uterus  and  oviducts;  in  the  male  the 
prostrate  and  vesiculae  seminales.  In  both  sexes  it  supplies  the  bladder, 
along  the  three  vesical  arteries  and  the  root  of  the  iliac  and  femoral.  In  the 
female  the  two  large  branches  of  the  hypogastric  plexus,  composed  of  twenty 
to  thirty  strands  of  nerves,  pass  off  from  the  region  of  the  inferior  mesenteric 
ganglion  and  end  distinctly  in  the  pelvic  brain  situated  on  each  side  of  the 
cervix.  In  the  male  these  same  branches,  though  less  in  size,  pass  to  the 
prostate  and  semen-sacs,  but  the  pelvic  brain  I  have  found  is  vastly  smaller 
in  males  than  in  females.  Yet  a  small  dog  possesses  quite  a  large  pelvic 
brain  on  the  side  of  the  prostate  and  ending  of  the  vas  deferens. 

The  pain  in  hypogastric  neuralgia  must  be  sought  for  in  the  anatomical 
tracts  and  periphery  of  the  plexus,  which  will  be  (a)  in  the  uterus  and  ovi- 
ducts, (b)  in  the  bladder,  and  (c)  on  the  path  of  the  iliaco-femoral  arteries 
(and  with  the  inferior  mesenterium),  the  rectum.  Also,  since  the  origin  of 
the  hypogastric  plexus  is  inseparably  blended  with  that  of  the  spermatic  and 
hemorrhoidal  plexus,  we  must  expect  to  find  more  or  less  pain  occurring  in 
the  ovaries,  testicles,  rectum  and  sigmoid. 

So  far  as  I  am  aware  Romberg  was  the  first  to  describe  the  hyperesthesia 
of  the  hypogastric  in  1840.  It  is  a  neuralgic  affection  manifested  by  tender- 
ness and  pain  in  the  hypogastric  region.  There  is  a  sense  of  pain  and  drag- 
ging in  the  pelvis,  i.  e.,  in  the  uterus,  oviducts,  bladder  and  to  some  extent  the 
rectum.  In  women  the  pain  is  spoken  of  as  dragging,  i.  e.,  as  if  the  uterus 
were  prolapsing.  The  characteristic  pain  is  paroxysmal,  periodic,  and  is  not 
relieved  by  changes  of  position.  Structural  changes  cannot  be  demonstrated. 
Since  it  is  not  practical  to  separate  the  inferior  mesenteric  plexus  from  the 
hypogastric  on  account  of  their  intimate  and  close  anatomic  relations,  we 


HYPERESTHESIA  OE  THE  NERVUS  VAS0M0T0R1US         309 

will  consider  that  the  hyperesthesia  of  the  inferior  mesenteric  or  hemorrhoidal 
plexus  is  intimately  blended  with  hyperesthesia  of  the  hypogastric  plexus, 
the  periodic,  and  is  not  relieved  by  changes  of  position  spoken  of  as  hemor- 
rhoidal neuralgia  or  neuralgia  of  the  rectum,  of  which  I  knew  a  typical  case 
for  ten  years.  Neuralgia  of  the  rectum  in  male  or  female  is  of  an  intense 
character.  It  is  apt  to  arise  at  night  in  an  abrupt  or  sudden  manner  and  con- 
tinue from  a  few  minutes  to  an  hour  or  two.  It  passes  away  as  abruptly  as 
it  arises.  It  creates  intense  suffering  The  best  relief  is  opium  suppositories. 
Venereal  excesses  appear  to  aggravate  it.  Coition  momentarily  relieves,  but 
it  returns  quickly  with  more  intense  vigor  than  ever.  In  venereal  excess  the 
neuralgia  may  extend  with  painful  exacerbations  along  the  urethra,  especially 
worse  after  coition. 

In  the  range  of  the  sympathetic,  neuralgia  is  frequently  followed  by  sec- 
ondary effects,  as  in  disturbed  circulation,  nutrition  and  secretion. 

The  treatment  of  hyperesthesia  of  the  hypogastric  and  inferior  mesen- 
teric depends  largely  on  its  supposed  etiology,  It  consists  in  sedatives  and 
evacuants,  hydrotherapy,  vaginal  and  rectal  douches,  electricity,  massage 
and  strict  diet. 

The  neuralgia  of  the  hypogastric  and  inferior  mesenteric  plexuses  exists 
almost  entirely  during  sexual  life,  and  especially  during  its  active  period,  and 
though  no  demonstrable  structural  lesion  may  be  found  in  the  plexus  of 
nerves,  yet  we  must  be  on  the  alert  to  remove  all  visible  physical  defects 
for  fear  that  the  neuralgia  is  the  secondary  effect  of  the  visible  ones.  The 
patient  should  be  treated  as  well  as  the  disease,  for  it  pertains  to  the  wide 
moral  fields.  Some  patients,  male  or  female,  describe  all  sorts  of  pains  about 
the  genitals  for  months,  and  finally  they  may  suddenly  disappear.  There  is 
a  strange  connection,  however,  anatomically  and  physiologically,  between 
the  nasal  mucosa  (and  the  olfactory  nerve)  and  the  genitals  (and  also  the 
rectum).  Hence,  it  may  be  that  valerian  and  asafetida  will  be  effective 
remedies.  A  stimulant  such  as  nux  vomica  is  often  very  beneficial.  The 
beneficial  effects  of  nux  vomica  on  the  hyperesthesia  of  the  hypogastric  plexus 
may  be  owing  to  the  close  relation  of  the  lumbar  portion  of  the  spinal  cord 
and  the  genitals,  for  nux  stimulates  the  nerves.  Some  old  writers  termed  the 
neuralgia  of  the  hypogastric  plexus  menstrual  colic.  It  must  be  admitted 
that  many  of  the  neuralgic  pains  spoken  of  by  patients  in  the  hypogastric 
regions  are  obscure  and  would  perhaps  fit  better  in  the  chapter  on  visceral 
neurosis. 

In  hyperesthesia  of  the  hypogastric  plexus  we  must  include,  for  conve- 
nience, the  pelvic  brain.  This  is  a  massive  collection  of  compound  ganglia 
similar  to  the  cervical  ganglia  and  the  abdominal  brain.  It  is  located  on 
each  side  of  the  uterus.  It  doubtless  rules  the  vaso-motors  in  the  uterus, 
innervates  the  uterus  to  a  large  extent,  and  is  accountable  for  innumerable 
pelvic  pains  and  for  the  irritable  and  tender  uterus  which  is  better  considered 
in  the  domain  of  visceral  neurosis. 

Hyperesthesia  or  neuralgia  of  the  spermatic  and  ovarian  plexuses  has 
occupied  the  attention  of  physicans  for  over  a  century.     Astley  Cooper  pub- 


310  THE  ABDOMINAL  AND   PELVIC  BRAIN 

ished  a  notable  work  in  1830,  and  Curling  wrote  later.  Romberg  wrote  on 
the  subject  in  1840. 

In  the  male  the  spermatic  plexuses  of  nerves  extend  from  the  origin  of 
the  spermatic  artery,  in  the  aorta,  to  the  testicle — a  long,  quite  rich  strand 
of  nerves.  The  pain  exists  mainly  in  the  testicle  and  extends  to  some  extent 
along  the  plexus,  i.  e.,  in  the  spermatic  cord.  The  testicle  is  generally 
slightly  tender,  occasionally  exquisitely  sensitive;  some  subjects  feel  the 
necessity  of  a  suspensory,  and  feel  unable  to  live  without  it.  Sometimes 
movements  cannot  be  tolerated  and  the  patient  lies  in  bed  carefully  protect- 
ing the  testicle  from  trauma  or  touching  the  bed  clothing.  If  the  testicular 
or  spermatic  neuralgia  becomes  intense  the  pains  radiate  down  the  thighs  into 
the  back,  irritability  of  the  stomach  and  even  vomiting  arising.  Spermatic 
neuralgia  generally  has  a  more  profound  effect  on  the  mind  than  other  similar 
neuralgias  outside  of  the  sexual  field.  The  subjects  become  melancholic, 
iose  ambition  and  become  full  of  hopeless  forebodings.  Many  of  the  subjects 
have  varicocele  in  various  degrees.  Spermatic  neuralgia  attacks  man's  sexual 
domain,  the  most  profound  and  dominating  human  instinct,  and  if  it  persist, 
sooner  or  later  the  mind  becomes  deeply  troubled.  The  patient  becomes 
really  possessed  with  a  sexual  mania. 

The  etiology  of  spermatic  neuralgia  is  not  fully  known,  but  it  prevails 
during  the  state  of  puberty  and  manhood.  It  is  a  disease  of  active  sexual  life 
only.  Cooper,  against  his  will,  removed  three  testicles  for  spermatic  neural- 
gia and  found  the  gland  to  be  perfectly  healthy.  Romberg  had  a  case  of 
spermatic  neuralgia  where  the  patient  insisted,  against  the  surgeon's  advice, 
that  the  testicle  be  removed ;  however,  eight  days  later  the  neuralgia  appeared 
in  the  other  testicle,  and  since  it  would  be  only  eight  days  until  his  coming 
marriage,  he  preferred  to  retain  his  last  testicle. 

I  have  observed  cases  of  spermatic  neuralgia  before  and  after  operation, 
and  am  opposed  to  operation  unless  a  palpable  lesion  exists.  In  males  ure- 
thral neuralgia  is  often  closely  connected  with  spermatic  neuralgia.  Such 
forms  are  aggravated  by  coition,  and  especially  excessive  venery.  Though 
urethral  neuralgia,  like  other  neuralgias,  leaves  no  demonstrable  pathology, 
yet  such  cases  have  frequently  had  a  history  of  gonorrhea,  or  excessive  ven- 
ery. The  passage  of  graduated  sounds,  electricity,  washing  out  the  bladder, 
the  prohibition  of  sexual  activity,  and  local  applications,  relieve.  Some  old 
authors,  as  Cooper,  think  that  these  neuralgias  belong  to  a  central  irritation, 
but  modern  investigations  would  tend  to  the  view  that  it  is  a  peripheral 
irritation. 

The  subject  of  ovarian  neuralgia  is  very  indefinite.  However,  it  is  not 
intended  to  deny  the  existence  of  such  a  disease,  but  the  difficulty  arises  in 
the  diagnosis.  It  appears  to  me  that  the  so-called  ovarian  neuralgia  should 
be  brought  within  the  domain  of  visceral  neurosis.  For  example,  every 
gynecologist  of  experience  has  observed  an  irritable  uterus,  but  it  should  be 
designated  under  the  term  visceral  neurosis  and  not  uterine  neuralgia.  The 
pain  of  so-called  ovarian  neuralgia  passes  down  on  each  side  of  the  lumbar 
vertebrae  into  the  pelvis.     The  pain  is  irregular,  periodic,  exacerbated  at  the 


NEURALGIA   OF   THE  NERVUS   IASOMOTORIUS 


311 


menstrual  flow,  and  generally  the  ovaries  are  tender.  There  are  certain 
women  who  complain  of  pains  in  the  region  of  the  ovarian  plexuses  for  years. 
Physical  examination  discloses  at  times  very  little,  if  any,  physical  defects. 
Yet,  by  close  observation  and  treatment  by  heavy  douches  and  boro-glycerin 
tampons,  one  will  fre- 
quently note  improve- 
ment. The  pelvic  organs 
feel  more  normal  than  at 
the  beginning,  hence  we 
rather  favor  some  form  of 
physical  defect,  congenital 
or  excessive  venery  or 
some  pathologic  imperfec- 
tion. With  this  view,  the 
irritable  uterus  of  Gooch, 
the  most  of  the  ovarian 
and  other  visceral  neural- 
gias, will  be  more  bene- 
ficially considered  under 
visceral  neurosis. 

Finally,  I  wish  to 
state  that  large  numbers 
of  subjects  complaining 
of  ovarian  neuralgia  can 
be  definitely  s  h  o  w  n  t  o 
suffer  only  from  pain  in 
the  skin  of  the  hypogastric 
region — it  is  hyperesthesia 
of  the  periphery  of  the 
ilio-guinal  and  ilio-hypo- 
gastric  nerves. 

Hyperesthesia  of  the 
gastric  plexus,  gastric  neu- 
ralgia, is  generally  known 
as  gastralgia  or  gastrody- 
nia.  Much  that  was  said 
in  regard  to  neuralgia  of 
the  abdominal  brain  ap- 
plies to  gastralgia.  Also, 
it  may  be  better  to  include 
many  of  the  considerations 
of  gastralgia  in  the  chap- 
ter on  visceral  neuroses. 
Gastralgia  leaves  no  visi- 
ble trace  of  its  pathology. 
But  in  gastralgia  we  may 


X-RAY   OF  DUCTUS   PANCREATICUS   AND   PART 
OF  DUCTUS   BILIS 

Fig.  75.  This  illustration  suggests  the  quantity  of 
nerves — ensheathed  by  a  nodular,  fenestrated,  anastomos- 
ing plexus — supplying  these  channels. 


312  THE   ABDOMINAL   AND   PELVIC  BRAIN 

look  for  perverted  function  of  the  stomach,  as  in  (a)  sensation,  (b)  secretion 
and  (c)  motion.  A  typical  gastralgia  is  called  up  in  some  subjects  by  taking 
ice  water  just  following  meals;  in  others,  the  gastralgia  may  occur  at  any 
time.  The  chief  conditions  under  which  gastralgia  is  met  induces  the  convic- 
tion that  it  is  secondary  to  some  visceral  disturbances,  and  hence  the  subject 
is  better  placed  under  visceral  neuroses. 

The  Hyperesthesia  of  the  Cervical  Ganglia. — Ganglia  of  such  vast  size 
and  possessing  so  much  physiologic  influence  as  the  cervical  must  be  consid- 
ered being  subject  to  the  same  diseases  as  other  similar  ganglia.  Those  who 
have  studied  the  sympathetic  from  clinical,  experimental  and  autopsic 
grounds,  chiefly  agree  that  the  main  pathology  is  found  in  the  cervical  and 
great  abdominal  ganglia.  The  chief  influence  of  the  cervical  ganglia  is  man- 
ifest on  the  eye,  vessels  of  the  head  and  neck  and  the  heart. 

The  Hyperesthesia  or  Neuralgia  of  the  Cardiac  Plexus  (Angina  Pectoris. 
Stenocardia,  Heberden's  Disease,  1768)  is  a  painful  affection  of  the  nerves 
of  the  heart.  It  is  so  far  not  anatomically  definable,  but  is  undoubtedly  con- 
nected with  the  sympathetic  nerve. 

Angina  pectoris  is  a  disease  based  on  no  one  factor,  but  depends  on  a 
group  of  factors,  which  appear  to  have  origin  in  the  cardiac  plexus.  It  is 
characterized  by  its  marked  tendency  to  recur  in  paroxysms  occasionally  of 
intense  severity.  In  one  case,  a  man  fifty  years  of  age  attended  by  my  col- 
league, Dr.  O.  W.  MacKellar,  the  patient  was  attacked  with  angina  pectoris 
and  died  in  six  hours.  Hypodermic  injection  of  morphine  did  not  appear  to 
give  relief.  In  conjunction  with  Dr.  MacKellar,  I  performed  a  postmortem 
on  the  patient's  body  fifteen  hours  later.  I  found  the  heart  large,  dilated, 
slight  fatty  degeneration  and  the  coats  of  the  coronary  arteries  a  little  thick- 
ened. The  fatty  degeneration,  the  sclerosis  of  the  coronary  arteries  and  the 
dilatation  of  the  cardiac  walls,  were  distinct  enough  to  be  easily  observed, 
but  not  of  a  remarkable  type. 

One  of  my  patients  has  suffered  attacks  of  angina  pectoris  for  eleven 
years.  Otherwise  she  has  enjoyed  fair  health.  Angina  pectoris  originates  in 
the  circulatory  system,  which  is  ruled  by  the  sympathetic. 

The  lesion  of  angina  pectoris  is  so  variable  and  uncertain  that  it  is  impos- 
sible to  designate  its  pathology.  The  cardiac  plexus  is  so  intimately  and 
closely  connected  with  the  abdominal  brain,  both  anatomically  and  physio- 
logically, that  each  involves  the  domain  of  the  other.  In  angina  pectoris  the 
cardiac  plexus  and  abdominal  brain  are  in  such  a  state  of  hyperesthesia  or 
irritability  that  at  any  time  a  terrific  attack  may  arise.  The  attack  comes  on 
suddenly,  frequently  after  some  brisk  exercise  or  mental  activity.  John 
Hunter  died  in  a  paroxysm  of  angina  pectoris,  brought  on  by  an  altercation 
with  hospital  authorities. 

The  pain  begins  in  the  re|fcm  of  the  heart,  but  rapidly  radiates  in  other 
directions,  especially  down  the  left  arm  even  to  the  fingers,  perhaps  by  means 
of  the  nervous  tract  made  by  the  junction  of  the  intercosto-humeral  (second 
dorsal)  and  the  lesser  cutaneous  nerve  (nerve  of  Wrisberg).  The  patient  dur- 
ing the  attack  is  profoundly   affected.     The  face  shows  anxious  dread  and 


HYPERESTHESIA  OF  THE  NERVUS  IWSOMOTORIUS         313 

fear  of  impending  death.  The  pulse  may  be  small,  quick  and  irregular.  Res- 
piration is  labored,  the  face  is  pale  and  the  patient  presents  a  picture  of 
terrible  distress.  One  of  my  patients  required  a  couple  of  days  to  recover 
from  an  attack,  fearing  a  recurrence  by  any  active  movement.  The  attacks  of 
angina  pectoris  are  uncertain  in  intensity,  regularity  or  even  in  the  organs  most 
severely  attacked.     Hence,  the  varying  accounts  of  different  observers. 

The  essential  features  which  we  have  observed  in  the  attacks  are  (1) 
pain  in  the  cardiac  region;  (2)  profoundly  anxious  feeling  of  the  patient, 
and  (3)  disturbed  heart  action.  The  disturbed  respiration  may  be  due  to  the 
terrible  pain  accompanying  the  attack.  That  the  paroxysmal  pain  in  angina 
pectoris  arises  in  the  cardiac  plexus  we  do  not  doubt,  but  why  it  arises  there 
and  why  it  is  paroxysmal  we  can  only  guess,  as  we  are  still  doing  in  other 
neuralgias.  If  it  is  due  to  ossification  of  the  aorta  and  coronary  arteries  and 
consequent  pressure  on  the  adjacent  cardiac  plexuses  of  nerves,  why  does  it 
occur  so  far  apart  and  in  such  a  paroxysmal  character?  The  sympathetic  cardiac 
nerves  come  from  wide  areas,  hence  varied  and  widely  distinct  pain.  Each 
of  the  three  cervical  ganglia  on  each  side  sends  a  nerve  to  the  cardiac  plexus 
and  there  repeatedly  anastomoses  with  the  vagus. 

There  is  a  form  of  angina  pectoris  which  has  its  origin  or  influence  in 
the  abdominal  viscera.  It  is  a  reflex  neurosis.  The  far-famed  experiment  of 
Goltz  served  as  the  ground  of  this  view.  Goltz's  "percussion  experiment" 
consists  in  tapping  the  intestines  when  the  heart  may  be  arrested  (in  dias- 
tole). This  idea  serves  perhaps  to  explain  deaths  from  a  blow  on  the  pit  of 
the  stomach,  i.  e  .,  on  the  belly  brain.  Hence,  disturbance,  pathologic  con- 
ditions in  the  peritoneal  viscera,  may  produce  angina  pectoris  by  reflex  irri- 
tation, through  the  abdominal  brain.  Angina  pectoris  seems  to  be  due  to  a 
super-sensativeness  or  over  susceptibility  of  the  nervous  system.  However, 
Lancereaux  found  in  a  case,  which  died  during  an  attack  of  angina  pectoris 
from  which  he  had  long  suffered,  pathologic  conditions  in  the  cardiac  plexus. 
So  far  as  I  have  observed  cases  of  angina  pectoris,  the  chief  successful  treat- 
ment consists  in  the  diligent  avoidance  of  sudden  active  exercise,  physical  or 
mental. 

There  are  some  different  factors  in  angina  pectoris  which  may  be  noted, 
as  (a)  spasm  of  the  heart  and  large  blood  vessels,  (b)  a  pure  neuralgia,  and 
(c)  a  vaso-motor  disturbance  produced  by  reflex  irritation.  In  any  or  all 
factors  it  appears  that  the  sympathetic  nerve  predominates.  The  abdominal 
brain  may  serve  as  an  irritating  factor. 

Hyperesthesia  of  the  splenic  plexus  has  not  received  a  description  for 
the  reason  that  it  does  not  produce  definite  demonstrable  symptoms.  The 
plexus  of  nerves  following  the  large  spiral  splenic  artery  from  the  abdominal 
brain  to  the  spleen,  lying  to  the  left  side  between  the  ninth  and  tenth  ribs, 
must  play  a  significant  role  in  life's  action.  The  section  of  the  large  splenic 
plexus  of  nerves  begun  by  Jasckhowitz  and  others  demonstrated  that  the  spleen 
had  something  to  do  with  the  deposit  of  pigment  in  various  parts  of  the  body. 
It  is  evident  that  the  spleen  is  not  a  very  active  viscus  in  producing  pain. 
Jasckhowitz  showed  that  irritation  of  the  splenic  plexus  and  branch  of  the 


314  THE   ABDOMIXAL   AXD   PELVIC   BRAIN 

celiac  axis  lessened  the  size  of  the  spleen,  while  ligation  of  the  splenic 
plexus  distended  the  spleen.  The  vasomotor  nerves  of  the  abdominal  viscera 
are  included  in  the  sympathetic.  In  several  hundred  personal  autopsies  I 
found  the  spleen  surrounded  by  peritoneal  adhesions  in  nearly  90  per  cent  of 
adult  subjects.  Hence,  it  would  be  difficult  to  decide  whether  the  pain  was 
not  due  to  the  old  perisplenitis.  But  the  spleen  is  innervated  from  the  same 
source  as  the  stomach,  and  there  is  no  reason  why  the  spleen  may  not  suffer 
from  neuralgia  as  well  as  the  stomach.  In  regard  to  the  neuralgia  of  the 
splenic  plexus,  it  will  be  required  to  work  it  out  along  the  line  of  experiments, 
and  especially  on  the  vasomotor  nerves. 

Hyperesthesia  of  the  hepatic  plexus  or  hepatic  neuralgia  (diabetes  mel- 
litus)  is  still  an  obscure  subject.  The  hepatic  artery  is  well  surrounded  by 
strands  of  sympathetic  nerves,  and  being  innervated  from  the  abdominal 
brain  or  the  same  source  as  the  stomach,  we  see  no  reason  why  the  liver  will 
not  suffer  neuralgia  pains  similar  to  the  stomach.  We  of  course  exclude 
from  hepatic  neuralgia  all  pain  produced  by  hepatic  calculus  or  demonstrable 
pathologic  lesion,  wherever  located — in  the  biliary  ducts,  gall-bladder  or 
common  duct.  Again,  pain  in  the  liver  might  arise  from  some  vicious  con- 
dition of  the  bile  inducing  a  form  of  colic  as  it  passed  through  the  ducts  to 
the  intestine,  and,  besides,  this  pain  would  be  of  a  periodic  or  neuralgic 
nature.  Hepatic  neuralgia  signifies  pain  in  the  region  of  the  liver  possessed 
of  a  periodic  nature.  It  may  be  in  hepatalgia  the  tangible  cure  is  overlooked. 
Inspissated  gall  may  cause  excruciating  pain  in  its  passage  and  be  found  in 
the  stool  in  dark  flakes.  The  passage  of  the  dry  flakes  of  gall  may  be  accom- 
panied by  severe  pain,  nausea,  exhaustion  and  vomiting.  The  right  vagus  as 
well  as  the  sympathetic  hepatic  plexus,  attends  on  the  liver,  so  we  must  view 
the  nerve  supply  of  the  liver  as  mixed,  but  since  the  vagus  below  the  diaphragm 
is  a  demedullated  or  sympathetic  nerve  the  final  action  is  the  same.  It  is 
found  that  certain  injuries  to  the  solar  plexus  make  more  blood  circulate 
in  the  liver,  and  consequently  an  increased  flow  of  bile. 

Some  writers  consider  that  there  is  a  casual  relation  between  hepatic 
neuralgia  and  diabetes  mellitus.  It  is  very  evident  among  writers  that  there 
exist  two  forms  of  hepatic  neuralgia,  viz.,  one  accompanied  with  pain  only 
in  the  hepatic  nerves,  and  one  with  pain  and  the  excessive  secretion  of  gly- 
cogen (diabetes  mellitus). 

Dr.  Powell  records  a  case  of  profuse  and  obstinate  sweating  with  con- 
gested liver  and  diabetic  urine.  Doubtless  the  hepatic  plexus  has  power  to 
rule  the  circulation  of  the  liver  to  produce  congestion  and  decongestion.  Hence, 
the  influence  of  the  sympathetic  nerve  is  very  great  in  diabetes  mellitus.  It 
includes  hyperemia  of  the  liver,  congestion  in  its  capillaries,  an  influence  on 
the  formation  of  glycogen  and  perhaps  on  the  ferment  necessary  for  its  pro- 
duction. But  since  the  production  of  diabetes  mellitus  is  a  very  complicated 
process  we  cannot  enter  into  its  details.  The  influence  of  the  sympathetic 
in  diabetes  mellitus  is  observed  in  the  menopause ;  when  the  hypogastric 
plexus  is  passing  through  a  stage  of  atrophy  women  frequently  have  sugar 
in  the  urine. 


NEURALGIA   OF   THE  NERVUS  I'ASOMOTORIUS 


315 


In  this  sense  diabetes  mellitus  is  identical  with  hepatic  neuralgia.  By 
some  irritation  transmitted  over  the  hepatic  plexus  the  circulation  of  the 
liver  is  increased,  and  the  glycogen  may  be  excessively  formed. 

The  uncertainty  and  variability  of  definite  lesions  in  diabetes  mellitus 
seem  to  prove  that  glycosuria  may  be  induced  by  reflex  irritation  in  the 
sympathetic.  Many  physiologists  believe  that  glycosuria  is  due  to  hyperemia 
of  the  liver.  Hyperemia  of  the  liver  is  controlled  by  the  sympathetic  nerve. 
Just  as  in  facial  neuralgia,  the  region  of  the  nerve  involved  is  surrounded  by 


X-RAY  OF  DUCTUS  BILIS  ET  PANCREATICUS  WITH  ARTERIA  HEPATICA 

Fig.  76.     This   illustration  presents  the   ducts   and  vessels   richly  supplying  the  liver — 
each  channel  is  well  ensheathed  with  a  nerve  plexus. 

congestion  or  hyperemic  vessels,  so  in  hepatic  neuralgia,  the  vessels  of  the 
region  of  the  hepatic  nerves  are  followed  by  dilation  and  hyperemia  and 
consequent  glycosuria.  It  is  not  irritation  of  the  hepatic  plexus  alone  that 
produces  glycosuria;  irritation  of  the  sciatic  is  followed  by  sugar  in  the  urine. 
Hyperesthesia  of  the  Pancreatic  Plexus. — Pain  in  the  pancreatic  plexus 
cannot  be  located  or  differentiated  from  hepatic  neuralgia.  The  late 
researches  of  Minkowski  would  indicate  that  diabetes  mellitus  is  due  to  dis- 
ease of  the  pancreas.  Minowski  and  Mering  have  done  much  valuable  labor 
in  the  field  of  the  pancreas  which  will  aid  in  solving  the  problem  of  the  rela- 
tion of  the  pancreas  to  the  diabetes  mellitus. 


316  THE  ABDOMINAL   AND   PELVIC  BRAIN 

Hyperesthesia  or  neuralgia  of  the  renal  plexus,  nephralgia  (diabetes 
insipidus)  is  an  affection  of  the  nerves  of  the  kidney  unaccompanied  by  any 
demonstrable  anatomic  lesion.  The  nerves  of  the  kidney  are  almost  entirely 
non-medullated,  i.  e.,  sympathetic.  The  kidney  has  the  richest  nerve  supply 
of  any  organ  in  the  body  except  the  uterus.  The  renal  artery  is  abundantly 
studded  with  large  ganglia,  and  the  nerve  strands  form  a  rich  network  about 
it.  The  kidney  is  closely  and  intimately  connected  to  the  abdominal  brain 
by  a  large  rich  plexus  of  nerves  and  ganglia.  The  anatomic  and  physiologic 
base  for  vast  influence  of  the  abdominal  brain  over  the  kidney  is  not  wanting 
in  abundance  of  demonstrable  sympathetic  nerves  and  ganglia. 

Knoll  (1671)  observed  polyuria  after  division  of  the  splanchnics.  He 
placed  canulas  in  the  ureters  and  then  divided  one  side  at  a  time,  so  that  he 
could  observe  the  variation.  On  the  side  operated,  the  urine  was  considera- 
bly increased  (hyperemia).  Some  writers  claim  that  neuralgia  of  the  renal 
plexus  is  accompanied  with  excessive  flow  of  urine,  polyuria  or  diabetes 
insipidus,  while  others  claim  that  neuralgia  of  the  renal  plexus  is  only  accom- 
panied by  pain  in  the  nerves  of  the  kidney  and  no  increase  of  urine.  In 
neuralgia  of  the  renal  plexus  all  renal  calculi  are  excluded. 

Neuralgia  of  the  renal  plexus  is  sometimes  intense  and  paroxysmal,  while 
at  other  times  it  is  more  continuous  and  less  severe.  The  pain  does  not  tend 
to  radiate  along  the  ureter  as  it  does  in  uretral  calculus.  It  is  met  with  in 
persons  exhausted,  anemic,  gouty,  rheumatic  and  those  poisoned  with  malaria. 
Exposure  to  wet  and  cold  are  liable  to  give  rise  to  renal  pain.  Sedatives, 
evacuants,  alteratives,  electricity  and  massage  are  remedies  employed  against 
the  disease.  It  is  very  evident  among  writers  that  there  exist  two  forms  of 
renal  neuralgia,  viz.,  one  with  pain  only  and  one  with  pain  and  increased  flow 
of  urine  (diabetes  insipidus).  With  a  large  sympathetic  plexus  rich  in  ganglia, 
there  is  no  reason,  except  from  experiment,  why  the  kidney  should  not  suffer 
neuralgia  similar  to  the  other  viscera,  as  such  a  condition  is  recognized  in 
the  nerves  of  the  stomach,  intestines,  ovaries  and  liver.  It  is  not  presumed 
to  exclude  cerebrospinal  influences  entirely. 

However,  the  renal  vessels  are  ruled  by  the  renal  plexus,  an  almost 
purely  sympathetic  apparatus,  having  its  origin  in  the  abdominal  brain. 

In  diabetes  insipidus  the  characteristic  feature  does  not  consist  in  any 
especial  malnutrition  of  food,  but  in  paralysis  of  vaso-motor  constrictor 
nerves  contained  in  the  renal  plexus  and  consequent  dilatation  of  renal 
vessels.  This  allows  excessive  blood  to  remain  in  the  kidney  (hyperemia). 
Much  of  diabetes  insipidus  depends  on  the  condition  of  the  circulating  blood 
in  the  kidney  brought  out  by  the  force  of  the  heart  and  constriction  or 
dilatation  of  the  renal  capillaries.  The  beneficial  influence  of  ergot  in 
diabetes  insipidus  demonstrates  that  the  disease  has  a  vaso-motor  origin  and 
maintenance. 

Some  writers  speak  of  an  idiopathic  form  of  renal  neuralgia,  which 
doubtless  means  that  its  origin  and  persistence  is  not  understood.  However, 
as  a  matter  of  clinical  knowledge,  it  is  very  rare  to  meet  with  actual  renal 
pain  unless  there  be  some  pathologic  lesion  of  the  kidney  or  a  renal  calculus 


HYPERESTHESIA  OE  THE  NERVUS  EASOMOTORIUS         317 

present.  But  I  have  met  with  persistent  pain  and  tenderness  in  the  kidney, 
which  neither  urinary  examinations  nor  renal  explorations  explained. 

It  is  not  probable  that  patients  will  persist  for  several  years  to  complain 
of  pain  and  tenderness  (sensativeness)  in  the  kidney  without  some  real  base. 
I  have  followed  some  for  long  periods  with  no  discoverable  pathologic  facts. 
It  is  like  renal  neuralgia. 

The  Hyperesthesia  of  the  Diaphragmatic  Plexus. — This  form  of  neural- 
gia has  not  been  described  as  far  as  I  am  aware.  The  diaphragm  is  so  thor- 
oughly dominated  by  phrenic  nerves  that  it  is  obscured  and  overlooked.  Yet 
the  diaphragm  is  distinctly  influenced  by  the  sympathetic.  Very  careful 
dissection  will  reveal  in  the  human  subject  a  large  nerve  connecting  directly 
the  inferior  cervical  ganglion,  the  ganglion  stellatum,  with  the  phrenic  nerve. 
Dilatation  of  the  rectum  induces  the  patient  to  bray  like  an  ass.  It  induces 
respiration — the  expiratory  moan.  In  peritonitis  the  experienced  abdominal 
surgeon  views  with  alarm  the  incipient  sighing  and  irregular  respiration. 
The  diaphragmatic  plexus  supplies  and  innervates  the  vessels  of  the  dia- 
phragm. The  ganglion  diaphragmaticum  exists  on  the  right  side  only,  at 
the  point  of  junction  of  the  sympathetic  and  phrenic  nerves.  The  dia- 
phragmatic plexus  is  connected  with  the  adrenal  and  the  hepatic  plexuses. 
Doubtless  some  of  the  sharp  pains  on  respiration  owe  their  origin  to  the 
sympathetic  in  the  diaphragm. 


CHAPTER  XXV. 

MOTOR  NEUROSES. 

The  rectum  is  guarded  by  two  sphincters,  vis.,  a  larger  proximal  one  supplied  by 
the  sympathetic,  and  a  smaller  distal  one  supplied  by  the  cerebrospinal 
nerves. 

"Our  greatest   danger   now   in  this   country   is  corporation  wealth" — Wendell 

Plumps. 

INTESTINAL    MOVEMENTS. 


In  experiments  on  various  animals  and  by  clinical  observation  on  man 
we  may  note  various  kinds  of  bowel  movements.  For  the  purpose  of  making 
the  subject  more  intelligible  we  may  note  that  the  bowel  wall  is  composed  of 
an  outer  longitudinal  muscular  layer  and  of  an  inner  circular  muscular  layer. 
The  bowel  is  lined  by  a  mucous  membrane  and  covered  by  a  serous  or 
peritoneal  membrane.  The  arterial  supply  is  carried  from  the  celiac  axis  to 
supply  the  stomach  (gastric  artery) ;  from  the  superior  mesenteric  artery  to 
supply  the  small  intestines,  the  ascending  colon  and  transverse  colon;  from 
the  inferior  mesenteric  to  supply  the  descending  colon,  sigmoid  and  rectum — 
in  all,  three  segments  supplied  by  three  arteries.  The  nerve  supply  to  the 
intestines  is  from  three  sources: 

1.  The  cranial  nerve  (the  pneumogastric). 

2.  The  spinal  nerves,  especially  those  entering  at  the  distal  and  prox- 
imal bowel  segment. 

3.  The  sympathetic  system. 

The  nerve  supply  of  the  bowel  is  a  mixed  supply  of  cerebrospinal  and 
sympathetic.  In  the  sympathetic  nerve  supply  of  the  bowel  we  must  name 
some  four  sources,  viz. : 

(a)  The  Auerbach  plexus  (myentericus  externus),  situated  between  the 
circular  and  longitudinal  muscular  layers  of  the  bowel  wall.  It  is  a  nerve 
plexus  supplying  muscles. 

(b)  The  Billroth-Meissner  plexus  (myentericus  internus),  situated 
under  the  mucosa.  It  is  a  nerve  plexus  supplying  glandular  structure  and 
has  to  do  with  secretion. 

(c)  The  abdominal  brain  (the  solar  plexus),  situated  around  the  origin 
of  the  celiac  axis,  the  superior  mesenteric  and  renal  artery. 

(d)  The  lateral  chain  of  sympathetic  ganglia,  located  along  each  side 
of  the  vertebral  column.  From  this  chain  of  ganglia  arise  the  great  splanch- 
nic nerves  (three  or  four).  With  a  mixed  nerve  supply  we  must'  designate 
the  character  of  the  movement  by  the  nerve  which  preponderates.  The 
characteristic  movements  of  the  bowel  are  those  of  a  rhythm,  rising  biowly 
to  a  maximum  (spasm)  and  sinking  slowly  to  a  minimum  (rest). 

The  ryhthmic,    periodic  movement  belongs  to  the  sympathetic  nerve. 

318 


INTESTINAL    PERISTALSIS  319 

So  that  wherever  the  initiation  or  inhibition  of  motion  may  reside  for  the 
bowel  wall,  it  is  dominated  by  the  sympathetic  nerve,  like  all  other  abdom- 
ina1  viscera  With  this  mixed  nerve  supply  variously  localized  we  may  turn 
to  the  physiologic  movements  of  the  intestinal  tract: 

1.  The  peculiar  peristaltic  movements,  which  consist  of  a  contraction 
and  dilatation  of  the  bowel  lumen. — The  motion  is  towards  the  anus  and  the 
contents  move  in  the  same  direction.  The  most  typical  animal  which  I  have 
examined  to  study  the  bowel  peristalsis  is  the  rabbit.  In  the  rabbit  the  con- 
traction and  dilatation  of  the  bowel  wall  is  very  rapid,  traveling  a  foot  in  a 
few  seconds.  Of  course  this  rapid  traveling  cannot  force  the  feces  with  it. 
The  analward  wave  is  transmitted  from  one  segment  of  the  bowel  to  the 
other,  in  rapid  succession.  But  with  the  abdomen  open  and  the  bowel  struck 
or  pinched  or  irritated,  we  must  think  of  every  successive  physiologic  action. 
The  peristalsis  borders  on  pathologic  conditions.  In  fact,  one  can  really  see 
that  the  bowels  move  in  a  wild,  irregular  confusion.  By  pinching  the  bowel 
wall  with  the  finger  and  thumb  or  forceps  a  circular  constriction  will  arise 
which  resembles  a  pale,  white  ring,  almost  closing  the  bowel  lumen,  and 
persisting  awhile.  This  analward  alternate  contraction  and  dilatation  of  the 
bowel  wall  is  a  physiologic  process  of  the  bowel,  and  doubtless  is  not  accom- 
panied by  pain  unless  there  be  a  diseased  segment,  when  pain  may  arise. 
The  peristalsis  of  the  bowel  is  perhaps  limited  to  a  bowel  with  contents,  i.  e., 
its  contents,  or,  in  other  words,  mechanical  irritation  that  produces  physio- 
logic peristalsis.  In  laparotomy  if  one  will  observe,  the  empty  bowel  is 
nearly  always  still  unless  irritated  by  manipulation.  If  one  will  watch  the 
bowel  waves  of  peristalsis  it  will  be  apparent  that  the  peristaltic  waves  are 
limited  from  three  to  twenty-four  inches.  A  peristaltic  wave  will  start  and 
stop  within  a  localized  space.  In  the  dog  the  peristaltic  wave  is  neither  so 
rapid  in  its  travel  nor  does  it  seem  to  travel  over  such  a  long  distance.  The 
intensity  of  peristaltic  waves  is  most  marked  toward  the  proximal  end  of  the 
jejunum  where  the  muscular  fibers,  blood  and  nerve  supply  are  large.  The 
bile  and  pancreatic  duct  pour  their  contents  into  the  proximal  end  of  the 
bowel,  and  thus  impel  the  peristaltic  waves  to  force  the  contents  distalward. 
For  secretion  or  the  presence  of  any  bowel  contents  is  what  induces  peri- 
stalsis. 

2.  Another  form  of  bowel  movement  may  be  called  the  pendulum  move- 
ment. This  is  a  contraction  and  elongation  of  the  longitudinal  muscular 
layer  which  does  not  propel  the  contents  analward.  The  lumen  of  the  intes- 
tine remains  the  same.  The  pendulum  movement  of  the  bowel  is  localized 
and  limited  to  short  stretches  of  intestine. 

3.  A  third  kind  of  bowel  action  is  described  by  Professor  Nothnagel  as 
a  roll  motion.  Though  recognizing  Dr.  Nothnagel's  keen  observing  powers, 
I  cannot  see  anything  in  the  roll  motion  of  the  bowel  except  an  excessive 
physiologic,  or,  better,  a  pathologic  physiology  process.  It  is,  in  my  opinion, 
only  a  wild  or  stormy  peristalsis;  when,  for  example,  the  blood  contents,  gas 
cr  fluid,  go  onward  by  spells  or  jerks.  The  roll  motion  doubtless  includes 
those  peculiar  gurglings  which  every  individual  now  and  then  experiences. 


320  THE  ABDOMINAL  AND  PELVIC  BRAIN 

And  though  this  form  of  bowel  motion  is  not  accompanied  by  pain,  yet  it 
seems  to  border  on  the  pathologic  lines.  Of  course  almost  all  bowel  motion  of 
any  distinct  type  belongs  to  the  small  intestines.  Perhaps  one  can  scarcely 
ever  observe  the  large  bowel  motion  through  the  abdominal  wall,  if  it  be  in  a 
physiologic  state.  Perhaps  the  roll  motion  of  the  bowel  described  by  Noth- 
nagel  is  due  to  an  irregular  action  of  the  nerve  supply,  the  movements  of 
which,  as  Auerbach's  plexus,  may  become  disordered.  Formerly  I  thought 
that  the  large  bowel  did  not  share  but  a  very  small  part  in  the  excessive 
activity  of  blood  motion,  but  recently  I  found  a  two-inch  "invagination  of 
death"  in  the* ascending  colon  of  an  adult,  so  that  the  colon  engages  in  a  wild, 
disordered  motion  of  death  when  the  cerebrospinal  system  has  lost  control 
forever  of  the  bowel  motion  (sympathetic). 

Peristalsis  of  the  small  intestines  does  not  consist  of  waves  starting  at  the 
duodenum  and  extending  to  Bauhin's  valve,  but  the  small  peristalsis  consists 
of  local  waves  which  start  and  cease  within  perhaps  six  inches  to  two  feet. 
One  may  recognize  peristaltic  waves  in  the  same  animal  two  to  three  or  four 
feet  apart,  each  going  through  its  wave.  Now  it  appears  that  bowel  contents 
cause  the  excitants  of  bowel  peristalsis,  and  even  if  one  observes  a  full  bowel 
quiet,  it  does  not  necessarily  overthrow  the  idea  that  bowel  contents  alone 
excite  bowel  peristalsis.  Empty  intestines  are  still  unless  excessively  stimu- 
lated. We  must  look  for  the  primary  anatomical  point  of  motive  force  of 
the  bowel  muscles  in  Auerbach's  plexus.  Among  the  very  unsatisfactory 
experiments  are  those  attempting  to  find  out  the  location  of  a  nervous  center 
for  bowel  movement.  Prlueger  discovered  that  when  the  splanchnics  are 
stimulated  the  bowel  motion  is  prohibited,  the  bowels  become  pale  and  the 
blood-vessels  become  narrowed  ('anemic) ;  but  severing  the  splanchnics  induces 
increased  bowel  peristalsis,  the  bowels  become  more  filled  with  blood  and  con- 
gestion occurs.  Some  assert  one  thing  and  some  assert  another  in  regard  to 
the  influence  of  the  vagus  over  the  intestinal  motion. 

Ludwig,  Nasse,  Kupffer,  Mayer  and  Basch  found  in  the  splanchnic  prohib- 
itory and  vase-motor  nerves,  besides  nerves  which,  by  stimulation,  irritated 
motion  in  the  bowel.  Also  Mayer  and  Basch  could,  by  irritating  the  vagus, 
prohibit  intestinal  movement.  Basch  and  Erhmann  believed  from  experi- 
ments that  the  splanchnics  were  the  motor  nerves  of  the  longitudinal  muscular 
layer  and  the  prohibitory  to  the  circular  muscular  layers,  and  that  the  vagus 
stirred  up  the  circular  muscles  while  it  prohibited  the  longitudinal  muscles. 
Fellner  claims  that  he  found  the  nervi  errigentes  to  be  the  source  of  longitudi- 
nal muscular  action,  while  the  hypogastric  nerves  were  the  motor  nerves  for 
the  circular  muscles.  Lately  Steinach  claims  that  the  motor  innervation  of 
the  intestinal  tract  is  through  the  posterior  sensitive  roots  of  the  spinal  cord. 
The  portion  of  the  colon  supplied  by  the  inferior  mesenteric  artery,  i.  e.,  the 
descending  colon,  sigmoid  and  rectum,  have  an  analogous  supply  to  the  upper 
portion  of  the  digestive  tract.  The  nerves  from  the  spinal  cord  pass  through 
the  rami  communicantes,  through  the  lateral  chain  of  sympathetic  ganglia 
into  the  hypogastric  plexus  mesentericus  inferior,  which  plexuses  supply  the 
sigmoid,  rectum  and  descending  colon.     The  lumbar  region  was  proven  by 


PERISTALSIS    OF    TRACTUS    IXTESTIXALIS 


321 


Goltz's  experiment  to  have  a  motor  center  for  the  rectum.  In  this  case  the 
spinal  nerves  course  through  the  hypogastric  and  mesenteric  plexuses  to  act 
as  motor  nerves  for  the  bowel.  The  sympathetic  nerves  and  ganglia,  the 
unconscious  motors  of  the  assimilating  laboratory,  work  steadily  while  the 


NERVUS   VASOMOTORIUS— GENERAL  VIEW 
Fig  77.     The  abdominal  portion  was  accurately  dissected  from  specimen  under  alcohoL 


21 


322  THE  ABDOMINAL  AND  PELVIC  BRAIN 

digestive  tract  has  any  contents.  It  is  entirely  analogous  to  the  uterus. 
When  there  exist  contents  in  the  uterus  its  walls  pass  and  repass  through 
constant  waves,  but  if  it  is  empty,  it  is  quiescent,  it  is  still.  So  it  is  with  the 
bowels,  an  empty  intestine  is  still  a  quiet  one ;  a  full  one  is  nearly  always  in 
motion. 

Anemia  of  the  intestines  lessens  the  peristalsis  while  hyperemia  increases 
the  peristalsis.  Chemically  indifferent  substances  will  create  bowel  motion 
according  to  their  deviation  from  the  normal  bodily  temperature.  It  must  be 
remembered  that  over  distention  makes  contraction  impossible,  i.  e.,  tym- 
panites is  paralysis  just  exactly  according  to  its  degree  of  distention.  Tym- 
panites is  accompanied  by  slight  peristalsis  but  the  pain  is  due  to  local  spasm, 
especially  of  the  circular  muscles.  It  appears  to  me  that  the  circular  muscles 
of  the  bowel  can  so  obliterate  the  lumen  that  it  practically  prevents  all  pas- 
sage of  contents.  Doubtless  the  muscles  would  sooner  or  later  tire  out  and 
admit  of  the  passages.  We  may  say  that  it  is  extremely  rare  to  observe  the 
physiologic  bowel  peristalsis  through  the  abdominal  wall.  But  it  is  not  at 
all  rare  to  observe  the  bowel  peristalsis  through  the  abdominal  wall  in  a 
pathologic  state.  In  the  normal  state  the  abdominal  wall  is  so  thick,  and 
the  change  of  shape  and  form  of  the  intestine  is  so  slight  that  one  can  seldom 
definitely  mark  out  bowel  peristalsis.  In  belly  walls  thinned  by  wasting  dis- 
ease and  muscles  thinned  and  separated  by  the  stretching  of  the  walls  one 
may  map  out  moving  bowel  coils  very  easily.  Especially  is  this  the  case  in 
bowel  obstruction. 

Peritalsis  of  a  pathologic  character  may  be  (a)  an  increase  of  normal 
movement,  (b)  tonic  contraction,  or  (c)  the  so-called  antiperistalsis.  The 
rolling  motion  of  the  bowel  described  by  Prof.  Nothnagel,  I  would  call  patho- 
logic. If  one  will  open  dogs  with  peritonitis  there  may  be  observed  irregular 
bowel  movements;  sharp  contraction  of  both  longitudinal  and  circular  mus- 
cles. In  fact  the  peristalsis  has  become  irregular,  excessive,  wild.  The  slow, 
normal,  pendulum  movements  of  dilatation  and  contraction  of  gut  have  been 
displaced  by  violent  movements.  The  bowel  movement  or  peristalsis  is 
accordingly  violent  and  wild  as  the  bowel  wall  is  inflamed.  One  may  observe 
increased  bowel  peristalsis  from  (a)  irritating  foods,  (b)  from  strong  doses  of 
physic,  (c)  in  sudden  mental  disturbances,  (d)  in  neurotic  patients,  (e)  from 
hot  or  cold  fluids,  drinks  or  foods,  (f)  in  enteritis  or  peritonitis,  (g)  especially 
in  intestinal  stenosis,  (h)  the  absorption  of  lead  into  the  system,  (i)  exposure 
to  cold.  It  did  not  appear  to  me  that  traveling  of  dogs  increased  the  peristal- 
sis, yet  in  general,  motion  aids  to  increase  peristalsis.  The  important  tetanic 
bowel  contraction  is  significant,  for  in  experiment  one  can  observe  by  pinching 
a  piece  of  bowel  it  will  contract  into  a  pale  white  cord,  perhaps  entirely  clos- 
ing the  lumen  for  all  practical  purposes.  The  tetanic  contraction  slowly 
yields  its  spasm,  but  doubtless  is  accompanied  with  terrific  pain.  For  almost 
every  drop  of  blood  is  driven  out  of  the  intestinal  wall  and  the  nerves  are 
pressed  in  a  traumatic  state.  If  neuralgia  is  a  demand  for  fresh  blood,  surely 
this  is  a  typical  example. 

Doubtless  in  the  violent  pain  of  lead-colic  (colica  saturina)  the  intestine- 


PERISTALSIS   OF    TRACTUS   LXTESTINALIS  323 

is  contracted  to  a  white  rod  and  the  condition  of  persistent  pain  depends  on 
various  segments  being  successively  attacked.  Tonic  contraction  of  the 
intestine  is  a  frequent  condition  of  bowel  stenosis.  If  one  will  sit  down  by 
a  patient  with  sufficient  bowel  stenosis  to  produce  obstruction  of  the  bowel 
contents,  by  placing  the  hand  on  the  abdomen  he  can  easily  perceive  the 
bowel  movements,  because  in  such  patients  the  belly  wall  is  usually  thin.  The 
bowel  movements  are  almost  constantly  felt,  they  gradually  increase  until 
the  small  intestine  may  feel  as  hard  as  a  rolling-pin  under  a  sheet,  and  such  a 
hard  bowel  will  gradually  relax,  when  the  same  phenomenon  will  appear 
elsewhere.  It  is  quite  probable  that  progressive  peristalsis  is  not  accom- 
panied by  pain,  no  matter  how  lively  it  is.  But  tonic  or  spasmodic  contraction 
of  the  bowel  can  be  and  is  accompanied  by  the  most  sickening  pain.  The 
chief  pain  from  the  bowels  (colic)  no  doubt  arises  in  disturbed  or  disordered 
peristalsis. 

Local  inflammation  in  the  intestine  producing  an  irritability  of  the  pe- 
ripheral nerves,  induces  irregular,  disordered  and  wild  bowel  contractions  with 
severe  pain.  Much  has  been  said  by  writers  in  regard  to  antiperistalsis,  i. 
e.,  peristaltic  wave  directed  toward  the  pylorus  instead  of  toward  the  anus. 
I  have  studied  this  subject  considerably  in  an  experimental  method,  but  have 
never  been  able  to  see  distinctly  anything  but  very  irregular  antiperistaltic 
waves.  I  tried  Prof.  Nothnagel's  claims  that  sodium  salts  made  antiperistal- 
sis, and  that  potassium  salts  induced  peristalsis,  but  after  several  trials  on  dogs 
to  test  the  direction  of  the  intestine  I  could  not  consider  it  of  any  practical 
value,  neither  could  I  confirm  his  assertions.  After  laparotomy  we  frequently 
observe  considerable  pain,  and  almost  always  accompanying  this  pain  there 
is  more  or  less  tympanites.  The  pain  is  due  to  irregular  contraction  of  the 
intestinal  wall.  Segments  of  the  bowel  become  over-distended,  which  is  a 
kind  of  partial  paralysis  and  it  cannot  again  contract.  This  distended  portion 
does  not  give  pain.  The  pain  arises  from  the  non-distended  or  partially  dis- 
tended segments  which  are  in  a  state  of  spasm,  irregular  contraction  and  with 
irritable  peripheral  nerves. 

Excessive  or  irregular  bowel  peristalsis  is  observed  among  hysterical  and 
neurasthenic  persons.  It  is  recognized  by  gurgling,  splashing  or  rumbling 
noises  in  the  abdomen.  It  arises  in  neurotic  persons,  yet  the  same  person 
generally  suffers  no  unpleasant  sensations,  except  the  mental  annoyance. 
The  rumbling  noise  has  no  especial  connection  with  mealtimes  or  drinking. 
If  it  occurs  in  women  it  is  apt  to  be  more  active  at  the  menstrual  time.  Men- 
tal influences  seem  to  play  a  role,  for  when  the  subject  works  or  directs  the 
mental  energies  away  from  the  phenomenon,  the  gurgling  generally  ceases. 
If  the  abdominal  walls  be  thin,  one  can  observe  the  intestinal  movements, 
which  are  confined  chiefly  to  the  small  intestines.  Other  subjective  symp- 
toms generally  fail;  however,  gas  may  be  belched.  The  diagnosis  of  excess- 
ive bowel  peristalsis  is  not  difficult  if  one  can  observe  the  patient  for  some 
time.  The  trouble  may  persist  for  weeks  and  normal  stools  continue  during 
the  whole  time.  Excessive  bowel  peristalsis  may  be  diagnosed  from  bowel 
stenosis  by  its  spontaneous  appearance  and  cessation. 


324 


THE   ABDOMLXAE   AND   PELVIC  BRAIN 


It  seems  a  characteristic  of  certain  persons  to  have  repeated  attacks,  and 
I  have  observed  such  attacks  for  many  years  in  certain  persons  at  certain 
times,  when  the  mental  faculties  were  either  on  a  sudden  tension  or  embar- 
rassed. It  is  reported  that  an  old  and  valuable  servant  felt  obliged  to  give 
up  waiting  on  account  of  repeated  attacks  of  loud  gurgling  when  she  was 
serving  at  mealtimes. 

Excessive  peristalsis  is  generally  confined  to  the  small  intestines.  The 
treatment  of  excessive  bowel  peristalsis  should  be  both  physical  and  mental. 
Hydrotherapy,  massage,  galvanization    of   the  abdomen   and    remedies   pro- 


DILATED   DUCTUS    HEPATICUS 

Fig.  78.  The  dilated  hepatic  ducts  impress  with  the  idea  of  the  quantity  of  nerves 
attending  the  ducts  in  the  form  of  a  nodular,  fenestrated,  anastomosing  plexus  ensheathing 
the  channels. 

foundly  affecting  the  olfactory  nerve,  aid  to  bring  about  normal  bowel  peri- 
stalsis. As  remedies  the  bromides,  arsenic,  iron  and  nux  vomica  are  valuable 
adjuncts.     The  regulation  of  the  diet  is  of  first  importance. 

Enterospasm  is  a  condition  of  the  bowel  in  which  the  longitudinal  or 
circular  muscular  layers  are  in  a  state  of  excessive  contraction.  To  see  an 
actual  demonstration  of  this  phenomenon,  the  most  practical  method  is  to 
open  a  rabbit's  or  a  dog's  abdomen  and  by  pinching  the  bowel  wall  with  the 


PERISTALSIS   OF   TRACTUS   INTESTINALIS  325 

finger  and  thumb  both  the  muscular  layers  will  be  observed  in  a  state  of 
spasm.  The  circular  muscular  layer  on  being  pinched  or  struck  will  contract 
to  a  small  white  ring  or  band.  The  enterospasm  is  likely  to  occur  in  very 
limited  segments  of  bowel.  If  it  be  primary,  it  is  a  motor  impulse,  but  it 
may  be  secondary  to  a  sensory  neurosis  when  it  is  of  a  reflex  nature.  In  such 
a  case  both  a  motor-neurosis  and  a  sensory-neurosis  exists,  that  is,  a  mixed 
neurosis. 

Enterospasm  is  primarily  a  motor-neurosis,  but  is  frequently  combined 
with  reflex  sensory  factors  inducing  severe  pain.  As  a  result  of  the  spasm 
irregular  constipation  arises.  The  stool  is  either  long  retained  or  forcibly 
expelled.  Enterospasm  may  owe  its  origin  to  misuse  of  cathartics,  the 
entrance  of  lead  into  the  system,  mental  effects,  worms  or  improper  use  of 
foods.     Meningitis  or  disease  of  the  cerebrospinal  axis  may  play  a  role. 

The  treatment  of  enterospasm  consists  of  opium  and  evacuants.  It  is 
this  form  of  constipation  that  the  old  physicians  said,  paradoxically,  opium 
cured.  It  cured  the  spasm  and  the  bowels  naturally  become  regular.  The  - 
proper  treatment,  however,  will  consist  more  in  diet  regulation,  colonic  flush- 
ings, in  electrical  treatment,  in  bromides,  nux  vomica,  in  massage  and  hydro- 
therapeutic  measures. 

Paralysis  of  the  bowel  signifies  that  the  contents  are  not  forced  onward, 
though  the  lumen  is  patent;  no  mechanical  obstruction  exists.  Henrot 
announces  three  forms: 

We  first  have  direct  paralysis  of  the  bowel  from  affection  of  its  walls,  as 
after  reduced  hernia;  often  trauma,  as  in  laparotomy,  after  peritonitis, 
enteritis,  etc. 

Second  we  have  indirect  or  reflex  paralysis,  as  from  injury  to  the  testicle; 
inflammation  of  a  bowel  segment,  as  inflammation  of  the  appendix,  pro- 
duces paralysis  of  large  bowel  segments,  the  irritation  being  reflected  to  the  ab- 
dominal brain,  reorganized  and  sent  out  on  the  various  nerve  plexuses,  laming 
the  said  segments.  An  abscess  in  the  abdominal  wall  may  by  reflex  action 
produce  paralysis  of  a  bowel  segment  sufficient  to  prevent  the  onward  move- 
ment of  the  feces.  In  many  autopsies,  experiments  on  animals  or  on  humans, 
I  have  noted  where  a  small  perforation  had  produced  paralysis  of  adjacent 
segments  by  spread  of  peritoneal  inflammation.  No  mechanical  obstruction 
existed.  This  is  what  one  continually  hears  of  as  obstruction  of  the  bowels 
— it  is  really  peritonitis.  The  paralysis  is  due  to  edema  and  exudates  pressing 
on  the  peripheral  nerye  apparatus  of  the  bowel  wall. 

Thirdly,  by  leaving  out  of  consideration  the  cerebrospinal  lesions  we 
have  bowel  paralysis  from  hysteria,  melancholia,  neurasthenia,  from  atony  of 
the  bowel  and  from  persistent  coprostasis.  It  must  be  remembered  that  the 
symptoms  of  ileusparalyticus  are  not  easy  to  diagnose  from  genuine  ileus. 
In  genuine  ileus  the  peristalsis  of  the  bowel  is  increased  on  the  proximal  side 
of  the  affected  locality.  The  therapeutic  application  for  any  form  of  ileus 
depends  entirely  on  the  original  cause.  Should  the  paralysis  depend  on  some 
neuroses,  the  treatment  will  be  regulation  of  diet,  electricity  and  massage  of 
the  abdomen,  the  careful  use  of  evacuants  and  moral  influences.  Colonic 
flushings  are  excellent  in  this  form  of  neurosis. 


326 


THE  ABDOMINAL   AX D   PELVIC  BRAIN 


Deficient  peristaltic  action  observed  in  old  age  and  anemic  persons  de- 
pends, perhaps,  much  on  exhaustion,  and  deficient  blood  of  a  proper  composi- 
tion. Besides,  deficient  peristalsis  means  deficient  secretion,  and  deficient 
secretion  means  an  empty  bowel,  and  an  empty  bowel  means  a  quiet  one. 
The  parenchymal  intestinal  ganglia  require  proper  blood  to  stimulate  them 
to  action.  The  peristaltic  movements  of  the  bowels  ".re  anatomically  excited 
by  the  distal  visceral  ganglia,  yet  they  receive  and  empty  feces  from  the 
abdominal  brain  impulses  to  accelerate  or  retard  the  bowel  motion. 

McKendrick  believes  the  accelerating  nerves  of  the  bowel  are  from  the 
sympathetic  ganglia,  while  the  prohibiting  nerves  are  from  the  lumbar  spinal. 


/     v.'t  V.   v--5v  •  v  V 


FIC.    2. — PELVIC    BRAIN. 

NERVES   OF  THE   INTERNAL  GENITALS 
Fig.  79.     Illustration  of  nerves  from  my  own  dissections. 


The  descending  colon  and  rectum,  according  to  Xasse,  receive  motor  fibers 
from  the  plexuses  of  nerves  surrounding  the  mesenteric  artery.  The  general 
notions  (Fox,  McKendrick,  Nasse,  Bridge,  Kolliker)  are  that  the  gastrointes- 
tinal ganglia  send  motor  fibers  to  the  bowel  muscle  and  that  these  automatic 
ganglia  are  stimulated  reflexly  by  fibers  running  from  them  to  the  mucosa 
(Henle).  Hence,  a  diarrhea  is  a  reflex  matter.  Pflueger  believed  that  the 
splanchnics  were  inhibitory  nerves  of  bowel  action,  but  Basch  showed  that 
the  splanchnics  were  inhibitory  nerves  only  in  a  secondary  manner  by  chang- 


I'liRISTALSIS   OF    TRACT  US   INTESTINALIS  327 

ing  the  circulation  in  the  bowel.  The  motus  peristalticus  in  lead  colic  is  of 
much  interest,  as  it  should  lead  to  the  source  of  bowel  motion,  but  the  special 
action  of  lead  on  tissue  is  not  yet  settled.  However,  it  belong*  without  doubt 
to  the  abdominal  sympathetic.  Is  the  disturbance  due  to  the  action  of  the 
lead  on  the  sympathetic  ganglia?  Does  the  lead  act  as  an  excitant  on  fibers 
of  the  splanchnics?  Both  views  may  be  retained  until  more  precise  data 
exist.  Begbie  asserts  that  irritation  of  the  abdominal  brain  (or,  as  he  says, 
plexuses  surrounding  the  aorta)  induces  active  movements  of  the  small  intes- 
tines and  colon.  Valentin  discovered  that  irritation  of  the  fifth  nerve  pro- 
duces invariably  movements  of  the  small  intestines.  We  must  remember 
that  the  fifth  nerve  is  par  excellence  the  ganglionic  cranial  nerve,  having  eight 
ganglia  situated  on  its  branches.  It  is  really  a  sympathetic  cranial  nerve. 
It  is  not  yet  clear  what  is  the  influence  of  the  cerebrospinal  system  over  the 
movement  of  the  abdominal  viscera,  but  observers  are  agreed  that  fear,  fright, 
emanations,  intensely  influence  the  bowel  movements,  showing  the  influence 
of  the  cerebrospinal  axis  on  the  bowel  and  sphincters.  How  much  is  this 
due  to  relaxation  of  sphincters?  As  Romberg  remarked  fifty  years  ago,  the 
field  of  influence  of  the  cerebrospinal  axis  over  bowel  movement  is  not  fully 
known.  From  personal  experience  we  know  that  ordinarily  the  passing  form  of 
colic,  bowel  spasm,  is  due  to  irritating  contents.  The  irritation  of  the  mucosa 
passes  to  the  automatic  ganglia  of  the  bowel  wall,  which  resents  the  trauma 
by  muscular  contraction ;  the  consequence  is  pain. 

The  motor  bowel,  automatic  parenchymatous  ganglion,  is  one  of  the  best 
samples  to  illustrate  the  highest  degree  of  independence.  The  influence  of 
the  sympathetic  nerve  upon  the  intestines  has  long  been  recognized.  The 
long  controversy  in  relation  to  the  influence  of  the  great  splanchnic  nerve 
upon  the  small  intestines  seems  to  be  more  definitely  settled.  Weber  showed 
some  years  ago,  that  the  splanchnic  exerts  an  inhibitory  action  upon  the 
intestines,  arresting  their  movement.  Legros  and  Onimus,  however,  claimed 
to  show  by  their  experiments  that  the  splanchnic  is,  on  the  contrary,  the 
motor  nerve  of  the  intestines,  and,  when  stimulated,  produces  contraction  of 
the  intestinal  walls. 

Recent  experiments  made  by  Coutade  and  Guyon  present  very  clear 
evidence  that  the  two  muscular  layers  of  the  intestine  are  controlled  by 
nerves  of  a  different  origin,  the  circular  layer  being  controlled  by  branches 
of  the  sympathetic,  and  the  longitudinal  by  the  spinal  nerves.  The  conclu- 
sions arrived  at  by  these  investigators  are  as  follows,  to  which  all  experi- 
menters do  not  agree : 

1.  The  sympathetic  causes  contraction  of  the  circular  muscular  layers 
of  the  intestine  and,  at  the  same  time,  relaxation  of  the  longitudinal  muscular 
coat. 

2.  The  contraction  of  the  small  intestines  depends  entirely  upon  the 
sympathetic,  and  is  wholly  independent  of  the  pneumogastric. 

Galvanization  of  the  abdominal  brain  induces  active  movements  of  the 
small  intestines  and,  to  a  certain  degree,  of  the  large.  Anatomic  and  physio- 
logic experiments  certainly  show  that  branches  of  the  abdominal  brain  take 
part  in  the  innervation  of  the  stomach. 


328  THE   ABDOMIXAL   AXD   PELVIC  BRA1X 

There  is  a  ceratin  kind  of  excessive  bowel  peristalsis  which  is  disastrous 
at  any  age,  but  especially  in  infancy.  I  refer  to  invagination.  One-quarter 
of  all  invaginations  occur  before  one  year  of  age,  and  one-half  of  invaginations 
occur  under  ten  years  of  age.  Invagination,  telescoping,  intussusception,  is 
where  one  segment  of  bowel  is  driven  into  the  adjacent  one.  Nearly  all 
invaginations  are  toward  the  anus  distalward,  but  some  report  invagination 
toward  the  stomach  proximalward.  Hektoen  reports  a  case  of  proximalward 
invagination.  Invaginations  are  especially  likely  to  arise  in  two  classes  of 
subjects,  viz.:  (a)  in  children  and  (b)  in  persons  dying  of  some  cerebrospinal 
trouble.  The  invaginations  found  in  autopsies  ma}*  be  called  the  invagina- 
tion of  death.  I  have  repeatedly  found  this  condition  in  human  and  animal 
autopsies. 

The  characteristics  of  the  invagination  of  death  are  that  the}-  are  accom- 
panied by  no  inflammatory  process,  no  exudates,  no  congestions  or  peritonitis, 
and  are  often  multiple.  In  one  dog,  dying  of  peritonitis,  I  found  four  points 
of  invagination  close  to  each  other.  They  were  invaginations  of  about  an 
inch  distance  each.  Several  times  in  human  autopsies,  I  have  found  from 
one  to  four  points  of  invagination.  The  characteristics  of  ordinary  invagina- 
tion are  that  it  is  accompanied  by  severe  and  sudden  pain  and,  if  continued 
long  enough,  by  congestion,  exudation  and  inflammation  in  the  bowel  tunics. 
Finally,  the  apex  will  begin  to  bleed  and  slough,  producing  bloody  stools  and 
finally  peritonitis;  and  its  results  are  found  about  the  point  of  invagination. 

Invagination  is  due  to  irregular  action  of  the  muscles  in  the  intestinal 
wall.  It  is  due  to  irregular  peristalsis.  In  children  and  persons  with  diseased 
cerebrospinal  systems  it  appears  that  the  cerebrospinal  axis,  the  higher  nerve 
center,  has  lost  its  normal  control  over  the  sympathetic,  which  rules  the 
bowels,  and  the  result  is  that  the  intestines  assume  wild  and  disordered  move- 
ments. Not  only  the  bowel  segments  but  their  longitudinal  and  circular  mus- 
cles begin  to  act  without  harmony,  irregular,  spasmodic.  In  infants  and 
children  it  appears  that  the  cerebrospinal  axis  has  not  assumed  full  control 
over  the  sympathetic  which  rules  the  bowel  muscles.  Since  invagination 
constitutes  one-third  of  all  forms  of  intestinal  obstruction,  regular  action  of 
the  gut  wall  assumes  an  important  role.  It  is  curious  to  note  the  common 
localities  of  invagination.  The  ileo-colic  and  ileo-cecal  constitute  50  per  cent, 
i.  e.,  50  per  cent  of  invaginations  occurs  at  the  ileo-cecal  valve.  Thirty  per 
cent  occur  in  the  small  intestines  and  20  per  cent  occur  in  the  colon. 
Omitting  the  region  of  the  ileo-cecal  valve  as  having  some  mechanical 
peculiarity  tending  to  invagination,  we  note  that  there  are  more  invagina- 
tions in  the  small  intestines  than  in  the  large,  which  must  be  due  to  a  greater 
possession  of  muscles. 


CHAPTER   XXVI. 
GASTROINTESTINAL  SECRETION. 

"Youth's  Lexicon  has  no  such  word  as  fail." — Bulucr. 
"It   is  our  hearers  zuho  inspire  us." — I'inet. 

1.  Gastrointestinal  secretion  is  a  significant  and  important  matter  in 
animal  life.  Gastrointestinal  secretions  are  under  the  control  of  the  sympa- 
thetic ganglia  located  in  the  walls  of  the  digestive  tract.  We  designate  those 
ganglia  in  general  as  the  Billroth-Meissner  plexuses  (plexus  myentericas 
internus)  situated  immediately  beneath  the  gastrointestinal  mucosa.  They 
rule  secretion.  We  cannot  properly  separate  the  submucous  nerve  plexus 
from  the  Auerbach's  plexus  (plexus  myentericus  externus)  which  rules  mus- 
cular motion  and  is  situated  between  the  circular  and  longitudinal  muscles  of 
the  gastrointestinal  tract.  One  nerve  plexus  is  a  complement  of  the  other. 
As  secretion  without  motion  is  of  little  avail,  and  motion  without  secretion 
is  equally  futile,  peristaltic  motion  is  necessary  to  sweep  onward  the  food  to 
be  attacked  by  fresh  glandular  secretion  and  to  eliminate  and  drain  the 
system  from  the  debris  of  food.  The  remnants  of  the  gastrointestinal  feast 
must  be  removed  by  peristaltic  movements. 

Besides,  secretion  is  doubtless  enhanced  by  the  massage  muscular  con- 
tractions. The  large  degree  of  independence  exercised  by  the  sympathetic 
ganglia,  especially  at  a  long  distance  from  the  cerebrospinal  center,  is  quite 
suggestive  that  there  will  be  local  as  well  as  general  gastrointestinal  mucous 
secretion.  From  the  very  construction  and  function  of  the  digestive  tract 
we  may  expect  local  labors  in  it.  At  several  localities  new  and  different 
secretions  are  added  to  the  onward  moving  food,  so  that  local  and  general 
digestion  and  secretion  must  occur.  I  repeat  that  secretion  and  digestion  are 
both  local  and  general  in  regard  to  the  digestive  tube.  Yet  the  whole  nerve 
apparatus  of  the  digestive  tract  is  a  delicately  balanced  matter  both  as 
regards  muscular  and  secretory  activity.  Let  us  call  up  matters  that 
daily  occur,  but  are  not  always  interpreted.  For  example,  a  person  eats 
some  cucumbers  or  other  indigestible  and  fermentable  substance.  At  the 
time  that  the  indigestible  substance  is  eaten  the  bowels  may  be  as  regular  as 
clockwork  and  the  feces  of  semi-liquid  character.  Ten  hours  after  eating 
the  indigestible  substance,  when  the  regular  stool  is  to  be  evacuated,  it  will 
be  observed  that:  (1)  the  stool  is  delayed,  the  desire  for  stool  is  checked; 
(2)  if  forced  evacuation  be  exercised,  the  stool  will  be  hard  and  relatively 
dry,  for  want  of  secretion  is  manifest  by  distinctly  formed  and  shaped  feces. 

Now  what  is  the  cause  of  this  disturbance?  The  cause  is  unbalanced 
secretion  due  to  reflex  irritation.  The  irritation  is  going  on  in  the  business 
portion  of  the  digestive  tract,  i.  e.,  in  the  small  intestines.     The  subject  is 

329 


330 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


conscious  of  this  disturbance  only  by  a  little  pain,  colic  and  excessive  peri- 
stalsis. He,  however,  notices  that  an  excess  of  gases  is  being  formed  and 
passed  per  rectum.  He  may  not  sleep  well,  but  recognizes  an  indefinable 
restlessness.  This  irritation  may  be  active  enough  to  produce  seminal 
emissions  during  sleep.  The  irritation  in  the  small  intestines  has  unbalanced 
the  mechanism  of  secretion,  so  that  it  is  called  away  from  the  large  intes- 
tine, causing  excessive  secretion  in  the  small  intestine,  and  hence  the  dry 
formed  feces  in  the  large.     It  is  very  likely  that  the  excessive,  deficient  or 


DUCTUS   BILIS   ET  DUCTUS   PANCREATICUS 

Fig.  80.  Drawn  from  cross  section  of  the  pancreatic  and  biliary  duct.  The  minute 
glands  of  Theile  may  be  observed  in  the  walls  of  the  ducts.  These  are  the  so-called  glands 
of  the  hepatic  duct.     The  figure  illustrates  the  vast  domain  of  secretion. 


disproportionate  secretions  may  occur  in  separate  localities  of  the  digestive 
tract,  just  as  peristalsis  of  the  tract  may  be  a  local  matter.  We  know  from 
experiment  that  peristalsis  may  arise,  continue  and  subside,  limited  to  a 
short  piece  of  intestine. 

The  view  of  local  disturbance  in  both  peristalsis  and  secretion  sending 
out  its  reflex  power  and  disturbing  the  whole  digestive  tract  is  in  accord  with 
pathologic  data.  For  example,  a  perforation  of  the  appendix  may  so  unbal- 
ance the  nerve  apparatus  as  to  feel  it  at  the  umbilicus.     It  is  a  reality.     The 


SECRETIOX    OF    TRACTUS   INTESTINALIS  331 

secretion  of  the  gastrointestinal  mucosa  is  entirely  beyond  the  control  of  the 
will.  In  secretions  we  are  especially  dealing  with  the  sympathetic  nerve,  for 
secretions  have  a  close  relation  to  the  size  of  the  blood  vessels. 

1.  All  glands  receive  vessels. 

2.  All  vessels  have  nerves  to  control  their  caliber. 

The  gastric  secretion  may  be  reviewed  in  regard  to  experimental  data. 
The  stomach  is  supplied  with  nerves  for  its  muscles  and  for  its  glands,  as 
motion  and  secretion  are  both  necessary  for  normal  digestion.  The  arrange- 
ment of  the  Auerbach  and  Billroth-Meissner  plexuses  is  similar  to  the  small 
intestines.  The  splanchnic  nerve  is  the  chief  vasomotor  nerve,  i.  e.,  vaso- 
dilator and  vasoconstrictor.  This  is  important,  for  secretion  in  general 
depends  on  the  blood  supply,  as  may  be  observed  in  location  in  the  season  of 
"rut,"  in  glandular  congestion.  But  the  gastric  glands  are  ruled  by  the 
sympathetic  nerves,  whose  chief  origin  exists  in  the  abdominal  brain. 

It  must  be  claimed,  however,  that  the  stomach  glands  can  act  independ- 
ently, from  sympathetic  influence  alone,  and  also  be  changed  or  modified  by 
the  cerebrospinal.  It  is  doubtless  true  that  there  are  not  only  vasomotor 
nerves  in  the  spinal  cord  but  that  the  abdominal  brain  is  a  great  vasomotor 
center,  in  that  the  abdominal  brain  regulates  the  amount  of  blood  to  the 
gastric  glands  and  consequently  the  amount,  and  to  a  certain  degree  the  kind, 
of  secretion  of  the  stomach.  Yet  there  must  be  secretory  nerves  in  the 
stomach  which  belong  to  the  sympathetic.  Candor  requires  the  statement 
that  the  full  knowledge  of  the  nerve  supply  of  the  gastric  glands  is  not  fully 
known. 

The  independence  of  the  sympathetic  ganglia  of  the  stomach  is  signified 
by  the  fact  that  the  chief  stimulus  to  the  gastric  secretion  is  food  in  the 
stomach.  It  is  asserted  by  some  that  stimulating  any  of  the  nerves  going 
to  the  stomach  does  not  influence  the  secretion,  for  it  it  found  that  secretion 
will  go  on  under  the  stimulus  of  food  when  all  the  stomachic  nerves  are 
severed.  It  is  claimed,  therefore,  that  the  sympathetic  ganglia  in  the 
stomachic  walls  are  sufficient  to  act  as  centers  for  secretion.  This  delegates 
large   and   significant   powers   to   the   sympathetic   ganglia. 

The  sympathetic  ganglia  are  especially  liable  to  reflex  irritation,  and 
nowhere  is  it  more  manifest  than  in  the  stomach.  The  gastric  secretion  is 
modified  by  reflex  stimuli  from  the  brain,  uterus,  kidney,  testicle,  ovary, 
heart  and  spinal  cord,  etc.,  etc.     Emotions  play  a  role  in  gastric  secretion 

The  successful  treatment  of  stomachic  disease  is  significant  in  methods 
of  stimulating  the  stomach,  as  irritating  its  mucous  wall,  which  not  only 
starts  secretion,  but  motion  as  well.  In  ordinary  stomach  diseases  there  are 
four  factors,  viz. :  (a)  excessive  secretion,  (b  )  deficient  secretion,  (c)  dispro- 
portionate secretion,  and  (d)  muscular  motion.  Washing  the  stomach, 
irritating  its  wall  with  instruments  or  coarse  food,  will  accomplish  much  in 
inducing  health.  Doubtless  this  is  the  action  of  nux  vomica  and  hot  water. 
The  clinging  germs  should  be  washed  from  the  dormant  stomach  wall  and 
the  muscular  movements  must  be  stirred  to  excite  natural  secretions.  It 
has    astonished   me   at  the  frequent   beneficial   results   of    irrigation   of   the 


332 


THE  ABDOMIXAL   AND   PELVIC  BRAIN 


stomach.  It  stirs  to  more  normal  rhythm  the  sympathetic  ganglia,  both  of 
secretion  and  motion.  Besides,  it  washes  from  the  stomach  wall  abnormal 
matter.  The  stomach  must  have  rest  and  repose  or  it  cannot  long  stand 
irregular  irritation  without  resentment  of  the  little  circulation  insults. 
Hence    the    distal    irritation    from  a  diseased    uterus,    oviducts  and  ovaries 


CROSS   SECTION   OF  URETER 

Fig.  81.     Presents  the  tunica  mucosa,  muscularis  and  serosa  of  the  ureter,  with  several 
nerve  ganglia  located  between  the  tunica  serosa  and  muscularis. 

sooner  or  later  unbalances  stomach  function  by  its  regular  passage  of  the 
traumatic  insults  to  the  abdominal  brain  where  reorganization  occurs,  perhaps 
with  multiplication  of  effects.  The  excitation  of  the  diseased  genitals  has 
no  season  of  rest,  no  day  or  night  repose,  but  at  any  or  all  times  it  rushes  and 
flashes,  now  tumultuous  or  turbulent,  now  pell  mell  and  explosive.     There 


SECRETION    OF    TRACTUS   IXTESTINALIS  333 

is  nothing  like  a  chronic  atrophic  myometritic  uterus  to  derange  and  unbal- 
ance the  gastric  secretion  and  motion. 

The  stomach  is  very  highly  supplied  with  blood-vessels  and  nerves, 
because  it  is  a  vast  and  complicated  laboratory,  requiring  much  energy  to 
hold  its  delicate  but  active  processes  in  the  balanced  order.  From  experi- 
mental data  we  may  view  the  stomachic  glands  as  under  the  control  of  the 
sympathetic  nerves,  i.  e.,  the  ganglia  in  them. 


Lv 


CHAPTER   XXVII. 
SECRETION-NEUROSIS  OF  THE  COLON  (MUCOUS  COLITIS). 

"You   can  fool  some   of   the  people  all  the  time,  and  all  of  the  people  some  of  the 
time,  but  you  cannot  fool  all  of  the  people  all  of  the  time." — Abraham  Lincoln. 

"Thinking  is  the  talking  of  the  soul  with  itself."  — Plato 

History  notes  that  Dr.  Mason  Good  gave  one  of  the  first  communications 
in  regard  to  the  above  disease,  in  1825,  under  the  name  "Diarrhea  Tubularis." 
Woodward  collected  the  literature  up  to  1879,  in  the  Medical  and  Surgical 
History  of  the  War  of  the  Rebellion,  Vol.  I.  Da  Costa  wrote  in  regard  to 
the  disease,  as  did  also  Leyden  in  1892.  Nothnagel,  in  1884,  wrote  an  excel- 
lent essay  on  the  disease,  naming  it  colica  mucosa.  In  1884  Krysinski,  of 
Jena,  wrote  an  inaugural  thesis  on  the  disease,  detailing  six  cases,  and 
sought  to  establish  as  its  cause  the  presence  and  effects  of  microorganisms. 
Leube  thought  it  a  nervous  affection.  Pick  has  recently  written  a  short 
essay  on  the  subject. 

Many  different  names  have  been  applied  to  this  disease  on  account  of 
the  various  views  as  to  its  causation.  If  the  disease  consists  of  an  epithelial 
inflammation,  a  catarrh,  we  may  be  satisfied  with  the  designation,  enteritis 
membranacea,  but  should  there  exist  only  increased  mucous  secretion, 
without  inflammation,  the  terms  colica  mucosa  would  be  more  significant. 
However,  my  studies  on  the  subject  have  induced  me  to  adopt  the  term, 
secretion-neurosis.  It  is  possible  that  there  are  two  ill-defined  affections  in 
this  field,  one  being  an  enteritis  and  the  other  a  simple  increase  of  the 
mucous  secretion.  Autopsies  are  so  rare  on  subjects  dying  of  secretion-neu- 
rosis of  the  colon  that  no  pathological  basis  is  as  yet  definitely  established. 
An  antemortem  diagnosis  must  be  confirmed  by  a  postmortem  examination 
before  any  pathology  can  be  accepted  or  established. 

All  observers  agree  that  secretion-neurosis  of  the  colon  is  indicated  by 
the  peculiar  formation  and  evacuation  of  the  stools.  The  clinical  symptoms 
are  colicky  pains  and  the  evacuation  of  masses  of  mucus.  The  mucous 
masses  may  consist  of  flat  long  bands  (even  membranes),  ribbons,  shreds  or 
rolled  tubes  or  scrolls.  Some  portions  assume  a  spiral  form.  Some  writers 
assert  that  the  masses  are  fibrinous,  but  I  have  examined  quite  a  number  and 
have  never  observed  fibrin.  The  mucous  masses  are  white,  grayish  white,  or 
a  color  due  to  the  mixing  of  mucus  and  feces,  yellowish  brown.  By  placing 
the  mucous  masses  in  water  they  unroll  and  partially  dissolve.  However,  the 
peculiar  form  of  the  mucous  masses  may  be  retained  if  they  are  kept  in  bot- 
tles of  water  for  several  days,  as  we  have  noted  in  one  case.  The  quantities 
of  these  masses  evacuated  by  some  patients  are  enormous.  A  female  attended 
by  Dr.  Lucy  Waite  and  myself,  would  occasionally  evacuate  nearly  half  a 

334 


SECRETION  NEUROSIS   OE   THE   COLON  335 

pint  of  mucous  membranes,  masses,  bands,  tubes  or  unformed  substances. 
In  a  male  the  evacuation  showed  more  string  or  ribbon-like  processes. 

All  observers  agree  that  women  are  the  chief  subjects  of  secretion-neu- 
rosis of  the  colon.  Litten  estimates  that  80  per  cent  are  women,  and  accord- 
ing to  Kitagawa  90  per  cent  are  female  subjects.  Dr.  W.  A.  Evans  says  that 
of  the  many  samples  sent  to  the  Columbus  Medical  Laboratory  80  per  cent 
are  from  women. 

I  had  a  typical  case  in  a  man  36  years  of  age,  who  had  the  disease  for  nine 
years.  Some  report  cases  in  men  and  children.  I  never  saw  a  typical  case 
in  a  child.  Almost  all  writers  agree  that  women  who  are  subjects  of  secretion- 
neurosis  of  the  colon  are  neurotic,  nervous,  hysterical  or  hypochondriac. 
The  men  possess  a  similar  neurotic  or  hypochondriac  tendency.  I  have  had 
several  mild  cases  in  men. 

Patients  afflicted  with  secretion-neurosis  of  the  colon  have  suffered  from 
constipation  for  long  periods  previous  to  the  outbreak  of  the  former  disease. 
This#accords  with  my  view  that  constipation  is  a  neurosis  of  the  colon,  or  fecal 
reservoir.  The  attacks  of  such  patients  are  irregular,  but  recur  for  years. 
Pain  of  a  colicky  nature  may  suddenly  arise  in  the  abdomen  and  continue 
until  masses  of  mucus  and  occasionally  feces  are  expelled.  The  attacks  of 
pain  may  be  extremely  severe,  especially  when  large  masses  of  mucus  are 
evacuated.  So  far  as  I  can  discover,  the  pain  is  chiefly  located  in  the 
transverse  and  descending  colon  and  the  sigmoid  flexure;  in  general,  over  the 
left  abdominal  region.  However,  when  the  colicky  pain  is  severe  and  con- 
tinuous, the  patient  may  complain  of  pain  in  the  whole  abdominal  region. 
Some  of  my  patients  complained  of  pain  running  down  the  legs.  Abnormal 
sensation  may  arise  in  the  genitourinary  organs.  After  the  evacuations  of 
the  mucous,  slimy  masses,  especially  the  larger  ones,  the  patients  appear  and 
report  themselves  to  be  entirely  free  from  pain.  Generally,  the  larger  the 
mucoid  masses  evacuated,  the  longer  the  patient  remains  free.  However, 
the  colicky  pains  may  be  coming  on  for  one  or  two  days  before  the  large 
masses  are  expelled.  If  the  evacuation  be  slight  in  quantity,  the  colicky  pains 
are  slight,  but  often  continuous.  The  appetite  is  generally  good,  except  at 
the  time  of  attack.  An  enema  will  occasionally  bring  away  very  large  masses 
of  slime.  Also,  there  are  patients  who  pass  the  mucous  masses  who  do  not 
report  nor  appear  to  suffer  pain.  Hence  two  classes  of  patients  present 
themselves,  viz.:  some  pass  mucous  masses  with  colicky  pains;  others  pass 
mucous  masses  without  colicky  pains. 

Nothnagel,  my  honored  teacher,  the  ablest  of  all  writers  on  the  subject, 
shields  himself  by  adopting  the  term  colica  mucosa  et  c?itcritis  membranacea. 
He  acknowledges  that  a  variety  of  pathological  processes  are  here  included. 
Krysinski  and  Mathieu  are  both  inclined  to  consider  the  affection  an  enteritis 
and  Krysinski  endeavors  to  show  that  certain  low  organisms  are  the  primary 
cause.  It  does  not  seem  probable  that  microorganisms  would  persist  for 
years ;  and  besides,  were  the  disease  caused  by  microorganisms  we  ought  to 
be  able  to  cure  it.  Krysinski  describes  patients  who  simply  gave  a  desire  for 
stool  without  colicky  pains,  i.  e.,  merely  "bearing  down  pains." 


336  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

Much  interest  is  manifested  by  writers,  in  the  stools  in  secretion-neurosis 
of  the  colon. 

Microscopically,  the  evacuation  consists  of  membranous  or  tubular  gray 
masses.  They  may  resemble  croupous  membrane  from  the  respiratory  pas- 
sages. The  mucous  masses  may  be  transparent  like  slime,  or  opaque  like 
fibrin,  of  a  grayish  white,  or  a  dirty  color  with  pigment  in  it.  Sometimes 
the  masses  consist  of  large,  wide  and  thick  leathery-like  membranes;  at 
other  times,  long  ribbon-like  bands  or  rope-like  coils.  The  mucous  masses 
nearly  always  come  away  alone,  unmixed  with  feces.  Sometimes  they 
resemble  the  swollen  jackets  of  baked  potatoes.  By  careful  manipulation 
in  water  the  masses  of  slime  will  generally  unfold  into  membranes;  hence 
the  term,  membranous  colitis.  They  ma}"  resemble  fascia  or  tendons,  or  one 
may  be  deceived  by  milk  coagula. 

Microscopically,  the  mass  substance  represents  a  hyaline  body,  which 
can  be  preserved  only  a  short  time  in  air,  alcohol  or  water.  Degenerating 
cylindrical  epithelia  of  almost  any  grade  can  be  noted.  The  slimy  mass 
represents  a  glassy,  unformed,  transparent  substance.  If  acetic  acid  be 
added  it  assumes  a  wavy,  striped  or  ground  glass  appearance.  Glandular 
epithelia  are  almost  always  found,  shrunken,  swollen  or  vacuolated.  .  Some- 
times vast  numbers  of  microbes  are  present,  cholesterin  crystals,  triple 
phosphates,  fecal  masses,  pigment  and  occasionally  round  cells. 

Chemical  examination  reveals  mucin,  or  mucin-like  material,  as  the 
chief  constituent.  This  may  be  considered  as  definitely  established,  as  it  is 
confirmed  by  Clark,  Thompson,  Perrond,  Da  Costa,  Hare,  Pick,  Nothnagel, 
Furbringer,  Hirsch,  Walter,  V.  Jaksch,  Krysinski,  Kitagama,  Rothmann, 
Littre,  Vanni,  Leube  and  Pariser,  a  sufficient  number  of  investigators  to 
settle  the  question.  Some  authors  assert  that  mucin  is  the  chief  constituent 
with  other  albuminous  bodies.  The  only  author  we  have  found  who  claims 
that  fibrin  exists  in  the  evacuations  of  secretion-neurosis  of  the  colon  is  P. 
Guttmann,  who  apparently  based  his  support  on  doubtful  microscopical 
examination. 

Pathological  records  are  rare,  on  account  of  the  scarcity  of  material  on 
which  to  establish  them.  Nothnagel  reports  a  case  of  secretion-neurosis; 
Rothmann,  one  which  was  examined  by  C.  Ruge.  Ruge  reported  that  "in 
spite  of  careful  examination  of  the  whole  intestinal  tract,  nothing  abnormal 
was  discovered."  The  above  patient  of  Rothmann  presented  a  typical 
picture  of  colica  mucosa,  but  died  from  a  duodenal  perforation. 

Rothmann  had  another  case  that  died  of  carcinoma  at  the  base  of  the 
skull.  The  patient  was  in  the  hospital  from  June  14  to  Nov.  2,  1892.  By 
taking  an  enema  the  patient  evacuated  large  masses  of  mucus  without  pain. 
He  made  no  complaint.  The  autopsy  showed  in  the  transverse  colon  (where 
it  did  not  contain  feces)  and  the  strongly  contracted  parts  of  the  descending 
colon,  injected  and  folded  mucosa.  Between  the  folded  mucosa  lay  products, 
partly  membranous,  partly  strand-formed.  The  parts  of  the  colon  filled  with 
membranes  contained  no  feces.  In  the  ascending  colon  there  were  no  mucous 
masses,  but  feces,  with  reddened  mucosa.     In  the  sigmoid  the  membranes 


SECRETION  NEUROSIS   OE   THE   COLON  337 

could  be  torn  from  the  reddened  mucosa  without  loss  of  substance.  Feces 
were  found  in  the  small  intestine,  which  had  reddened  mucosa.  The  chief 
mucous  masses  were  found  in  the  left  half  of  the  transverse  colon,  descending 
colon  and  sigmoid.  The  microscope  demonstrated  the  mucous  masses  in  the 
lower  colon  to  consist  of  mucin,  not  fibrin.  In  this  case  there  can  be  no 
doubt  of  the  existence  of  catarrh.  Just  on  this  point  of  catarrh  or  no  catarrh, 
investigators  are  divided. 

We  have,  then,  three  opinions  in  regard  to  the  nature  of  secretion-neu- 
rosis of  the  colon,  viz. : 

1.  That  it  is  an  enteritis  (catarrh). 

2.  That  it  is  simply  excessive  secretion  of  mucus  (mucous  colic). 

3.  That  it  is  secretion-neurosis  (nervous). 

In  general  visceral  neuroses  we  have,  (1)  motor  neuroses  (motus  peristal- 
ticus);  (2)  sensory  neuroses  (hyperesthesia  and  anesthesia);  and  (3)  secretory 
neuroses  (excessive,  deficient  and  disproportionate  secretion).  In  secretion- 
neurosis  of  the  colon  we  have  to  deal  with  a  patient  who  has  all  three  secre- 
tory disturbances,  i.  e. :  deficient,  disproportionate  and  excessive  secretion. 
These  patients  have  generally  been  long  sufferers  from  constipation  (deficient 
secretion).  Then  follows  disproportion-secretion,  but  that  is  not  so  evident, 
as  it  simply  produces  fermentation.  Finally  comes  the  formation  of  the 
habit  of  excessive  secretion  of  mucus.  Now,  this  excessive  secretion  of  mucus 
arises  from  the  unfortunate  habit  which  the  mucus  cell  had  formed  during 
the  early  but  prolonged  state  of  constipation.  The  mucus  cell  had  learned  a 
bad,  persistent,  nervous  or  irritable  habit  of  excessive  secretion.  After  a 
long-continued  bad  habit  of  secreting  excessive  mucus,  the  cells  were  unable 
to  change  their  mode  of  life  and  assume  normal  action.  Hence,  as  one  of 
the  etiological  factors  of  secretion-neurosis  of  the  colon,  we  will  assume  the 
depraved  cell  habit  from  reflex  irritation. 

A  second  factor  that  perhaps  plays  a  chief  role  is  genital  disease.  Secre- 
tion-neurosis of  the  colon  is  nearly  always  manifested  in  neurotic  persons  of 
the  female  sex.  Such  subjects  nearly  always  have  pelvic  disease.  Every 
gynecologist  knows  from  actual  experience  that  pelvic  disease  produces  con- 
stipation, a  fore-runner  of  secretion-neurosis.  Constipation  may  be  secondary 
to  genital  disease,  which,  through  reflex  action,  produces  in  the  bowel  defi- 
cient, excessive  or  disproportionate  secretion.  Disproportionate  secretion 
induces  fermentation,  causing  gases  which  distend  the  bowel,  resulting  in 
atony  and  deranged  nerve  action  in  the  epithelial  cell.  Irritation  from  the  dis- 
eased genitals  induces  the  development  of  toxins.  The  toxins  affect  the  tis- 
sues locally,  inducing  colitis,  if  not  epithelial  catarrh.  Besides,  the  absorp- 
tion of  toxins  induces  neurasthenia.  The  diseased  genitals  reflexly  lead  to  a 
train  of  conditions  which  induce  defective  nutrition  and  excretion.  The 
evacuation  of  glassy,  viscid  mucus,  subsequently  followed  by  grayish  shreds, 
extruded  with  pain,  is  pathognomonic  of  secretion-neurosis  of  the  colon. 
Gynecologists  frequently  observe  these  conditions  except  the  grayish  shreds 
and  mucomembranous  layers.     The  pain  on  defecation  may  be  but  slight. 

The  first  step  in  the  cure  of  such  patients  is  to  relieve  the  afflicted  geni- 
22 


338  THE  ABDOMLXAL  AXD  PELVIC  BRAIX 

tals.  when  improvement  often  supervenes.  In  one  of  my  patients  suffering 
from  chronic  pelvic  disease  and  also  typical  secretion-neurosis  of  the  colon, 
many  complex  neurotic  symptoms  of  an  intense  character  would  occasionally 
arise  at  the  time  of  the  evacuations.  She  presented  paroxysms  of  pain, 
intense  colic,  profound  hysterical  or  neurotic  symptoms,  rapid  pulse,  disturbed 
respiration ;  all  of  which  subsided  very  slowly  after  the  evacuation  of  mucus. 
Reflex  neuroses  of  an  intense  character  were  present.  In  the  intervals  she 
was  quiet,  presented  none  of  the  acute  egoism  of  the  hysteric,  and  apparently 
had  no  desire  for  attention  or  notoriety. 

The  differentiation  of  the  pathological  process  in  secretion-neurosis  of 
the  colon  may  be  aided  by  (a)  the  anatomic  pathologic  findings  in  autop- 
sies; (b)  by  analysis  of  clinical  cases;  (c)  by  examination  of  the  evacuations; 
and  (d)  by  comparison  with  analogous  processes  in  other  mucosa.  We  have 
spoken  of  the  findings  of  the  autopsy  and  in  the  evacuations;  but  too  much 
cannot  be  said  in  regard  to  the  correct  clinical  symptoms.  The  numerous 
names  applied  to  the  disease  show  that  its  clinical  symptoms  are  not  definitely 
agreed  upon. 

Colica  flatulenta  is  a  close  relative  of  secretion-neurosis,  as  is  also  the 
motor  neurosis  (motus  peristalticus)  of  the  digestive  tract.  They  consist  of 
invisible  derangements  of  the  sympathetic  nerve.  Secretion-neurosis  occurs 
in  subjects  who  can  in  almost  all  cases  be  demonstrated  to  be  neurotics. 

Comparison  with  similar  processes  in  analogous  structures  may  not  clear 
up  the  pathology  very  much.  In  bronchitis  crouposa  chronica,  a  similar  dis- 
ease in  a  similar  structure  (mucosa),  as  in  secretion-neurosis  of  the  colon, 
there  is  no  anatomical  change  in  the  bronchial  mucosa,  as  noted  by  B.  Littre, 
and  there  is  no  fibrin  present.  Klein,  Keelson  and  Beschomer  claim  that  the 
bronchial  membrane  and  coagula  in  bronchial  croup  are  thickened  mucus  or 
slime.  That  keen  and  able  observer,  Nothnagel,  vigorously  asserts  as  a  com- 
parison that  the  membranes  of  chronic  croup  speak  against  the  fibrinous 
product  and  inflammatory  nature  of  colica  mucosa.  However,  conflicting 
opinions  still  exist  in  regard  to  the  nature  of  the  membranes  in  bronchial 
croup. 

Do  we  receive  any  light  in  secretion-neurosis  of  the  colon  by  comparing 
it  with  dysmenorrhea,  which  was  first  described  by  Morgagni  in  1723,  and  col- 
pitis membrancea  by  Farre  in  185s?  The  number  of  terms  applied  to  mem- 
branous dysmenorrhea,  as  endometritis  exfoliativa,  endometritis  dessicans 
and  decidua  mesenteralis,  signifies  conflicting  opinions.  There  are  at  least 
two  irreconcilable  opinions  in  regard  to  membranous  dysmenorrhea,  the 
inflammatory  and  the  non-inflammatory  conditions.  It  appears  to  the  writer 
that  a  third  view  should  be  introduced,  viz.,  that  it  is  a  secretion-neurosis  of 
the  endometrium. 

However,  it  appears  quite  certain  that  there  are  two  conditions  classed  as 
membranous  dysmenorrhea,  viz.,  in  one  case  the  membrane  consists  of  fibrin, 
lymphoid  cells  and  red  blood  corpuscles— a  secretion-neurosis — and  in  another^ 
the  membrane  consists  of  a  cellular  infiltrated  endometrium— an  inflamma- 


SECRETION  NEUROSIS   OE   THE   COLON  339 

tory  process.  The  second  process  throws  off  the  endometrium  with  its  blood- 
vessels, cell  infiltration  and  utricular  glands.  Hence,  under  the  general  term, 
membranous  dysmenorrhea,  we  are  dealing  with  inilammatory  processes 
(endometritis),  and  a  secretion-neurosis  (a  fibro-lymphoid  membrane  enclosing 
accidentally  red  blood  corpuscles  from  diapedesisat  the  monthly  congestion). 
The  last  process  is  a  perverted  nerve-action — a  secretion-neurosis  of  the 
endometrium. 

In  an  intensely  lymphatic  organ  like  the  uterus  we  would  expect  more 
lymphoid  elements  in  the  membrane  than  in  the  colon.  This  would  account 
for  the  fibrin  and  lymph-cells.  Also  red  blood  corpuscles  are  found  in  the 
evacuations  of  colica  mucosa;  and  they  are  simply  more  numerous  in  the 
membrane  of  membranous  dysmenorrhea,  because  of  the  intense  endometric 
congestion,  proceeding  to  rupture  (diapedesis).  Again,  secretion-neurosis  of 
the  endometrium,  like  secretion-neurosis  of  the  colon,  evacuates  the  mucous 
membranes  with  or  without  pain,  and  at  irregular  intervals,  showing  a  sus- 
tained comparison. 

To  say  that  the  above  diseases  of  the  colon  and  uterus  are  forms  of  mal- 
nutrition or  deranged  innervation  means  but  little. 

In  secretion-neurosis  of  the  colon  an  explanation  of  the  string  and  net- 
formed  stools  may  be  made  from  the  contracted  condition  of  the  irritable 
muscle  of  the  colon,  which  is  thrown  into  folds,  recesses  and  grooves,  which 
allow  the  moulded  form  of  the  retained  secreted  mucus  to  persist.  It  may 
be  mentioned  that  some  confusion  in  diagnosis  may  arise  by  the  so-called 
colica  mucosa  and  enteritis  coexisting.  In  other  words  a  catarrh  and  secre- 
tion-neurosis of  the  colon  may  exist  together. 

The  prognosis  of  secretion-neurosis  of  the  colon,  is,  for  life,  favorable, 
but  for  recovery,  doubtful.  I  have  known  the  disease  to  continue  for  nine 
or  ten  years,  with  but  slight  changes.  However,  it  is  very  variable  in  its 
attacks,  and  very  erratic  in  its  occurrence. 

The  treatment  of  secretion-neurosis  of  the  colon  must  be  directed  to  the 
nervous  system,  by  habit,  diet,  physical  and  mental  exercise,  and  general 
moral  influences. 

Regular  daily  bowel  movements  should  be  secured  by  very  slight  use  of 
cathartics,  considerable  use  of  drinking  fluids,  and  diet  that  leaves  a  large 
residue.  Baths  (medicated)  twice  weekly  are  very  helpful.  I  have  made 
some  patients  happy  and  helpful  to  themselves,  by  urging  them  to  return  to 
their  regular  business,  which  have  been  stopped  by  other  physicians.  Cly- 
sters, and  high  rectal  and  colonic  irrigations,  aid  wonderfully  in  evacuating 
the  mucus.  Intestinal  antiseptics  (HgCl2),  slight  massage  and  long  rests  at 
night  are  beneficial.  Much  moral  influence  and  helpful  courage  is  given  a 
patient,  when  he  is  told  he  will  not  die  from  the  trouble;  for  thought  concen- 
strated  on  the  disease  makes  him  much  worse — produces  pathologic  physiol- 
ogy— particularly  because  he  is  almost  always  a  neurotic.  Electricity  aids 
physically  and  mentally.  Sexual  activity  should  be  especially  limited. 
Clothing  should  be  carefully  regulated  to  avoid  sudden  changes. 


340  THE  ABDOMIXAL  AXD   PELVIC  BRA IX 

CON'CLUSION'S. 

I.  These  diseases  should  be  termed  secretion-neurosis  or  enteritis.  The 
first  is  of  neurotic  origin  and  course. 

Both  secretion-neurosis  and  enteritis  may  co-exist. 

3.  Secretion-neurosis  of  the  colon  occurs  chiefly  in  neurotic  females. 

4.  It  is  closely  associated  with  genital  disease. 
It  is  frequently  preceded  by  constipation. 
The  continuation  of  the  disease  is  partly  due  to  an  irritable,  vicious 

habit  of  excessive  epithelial  activity. 

7.  The  disease  is  characterized  by  colicky  pains  with  the  evacuation  of 
mucous  masses. 

It  is  non-fatal,  variable,  capricious  and  erratic  in  attacks,  with  impos- 
sible prognosis  as  to  time. 

Microscopically,  the  evacuations  appear  as  membranous,  yellowish- 
white  masses  of  mucus. 

10.  Microscopically,  one  sees  hyaline  bodies,  cylindrical  epithelium, 
cholesterin  crystals,  triple  phosphates,  round  cells,  various  micro-organisms 
and  pigment. 

II.  Chemically,  the  evacuations  consist  of  mucin  and  albuminous  sub- 
stance. 

12.  Secretion-neurosis  of  the  colon  is  comparable  to  the  secretion-neu- 
rosis of  the  endomitrium  (dysmenorrhea  membranacea)  or  bronchial  croup. 

13.  Secretion-neurosis  of  the  colon  appears  to  be  limited  chiefly  to  the 
part  of  the  colon  supplied  by  the  inferior  mesenteric  ganglion,  i.  e.,  to  the 
fecal  reservoir. 

14.  It  is  a  disease  of  the  sympathetic  secretory  nerves  and  in  analogous 
to  disease  of  the  motor  and  sensory  nerves  of  the  viscera. 

15.  Its  treatment  consists  of  removing  the  neurosis,  which  lies  in  the 
foreground,  and  regulating  the  secretion,  which  lies  in  the  background. 

Regulation  of  diet — especially  limited  to  cereals,  vegetables,  milk,  eggs 
— exercise  in  open  air.  and  systematic  "visceral  drainage"  are  the  essentials 
in  treatment. 


CHAPTER   XXVIII. 

REFLEX    NEUROSIS    FROM    DISTURBED    PELVIC    MECHANISM. 

"Eternal  spirit  of  the  chainless  mind." — Byron. 
"I  'neasy  lies  the  head  that  wears  the  crown.'" — Shakespeare. 

The  testimony  in  favor  of  the  production  of  reflex  neurosis  from  dislo- 
cated genitals  is  ample  for  the  gynecologist.  To  the  physician  foreign  to 
gynecology  from  lack  of  knowledge  and  experience,  clinical  and  anatomical 
facts,  comparisons,  methods  of  successful  treatment,  the  domination  of  the 
sexual  system  and  instinct  and  controlling  power  of  genital  reflexes  over  other 
viscera,  in  fact,  all  legitimate  arguments  of  cause  and  effect,  should  be 
presented.  Distorted  mechanism  of  the  pelvic  structures  causes  genital 
dislocation.  Dislocation  of  structures  compromises  circulation  by  the 
strangulation  of  vessels  and  thus  induces  malnutrition.  Dislocation  of 
structures  traumatizes  nerve-trunks  and  nerve  periphery,  causing  pain  and 
reflexes  which  radiate  over  nerve-tracks  to  other  viscera  and  there  disturb 
motion,  secretion,  absorption  and  sensation.  Tension  placed  on  a  woman 
through  dislocated  genitals,  by  compromising  circulation  and  by  trauma  of 
nerve  periphery,  devitalizes  her  system  and  exposes  her  a  prey  to  intercurrent 
disease  and  to  the  great  functional  neuroses  (neurasthenia  and  hysteria).  The 
gynecologist  by  removal  of  the  gynecologic  dislocation,  i.  e.,  the  focus  of 
reflexes,  can  demonstrate  that  the  reflex  neuroses  will  disappear.  In  view  of 
the  prevailing  difference  of  opinion  between  neurologists  and  gynecologists 
as  to  the  consecutive  reflex  neurosis  of  genital  dislocation  a  careful  weighing 
of  the  data  is  demanded.  Careful,  comparative  examination  of  gynecologic 
cases  gives  a  definite  series  of  reflex  neuroses.  It  is  admittedly  difficult  in 
each  individual  case  to  establish  genuine  genital  reflex  neurosis.  The  diagno- 
sis must  be  made  by  exclusion.  Improvement  of  the  dislocation  and  lessening 
of  the  reflex  neurosis  under  rational  treatment  is  ocular  proof.  Certain  rare 
cases  arise  in  which  no  palpable,  pathologic  anatomic  changes  are  perceptible 
and  still  apparently  the  gynecologic  reflex  neurosis  exists.  There  are  no 
exceptions  to  the  rule.  If  an  organ  becomes  diseased  secondarily  to  genital 
dislocation  through  reflex  neurosis  a  correction  of  the  dislocation  may  not 
always  cure  the  organ.  For  example,  if  a  round  ulcer  appear  in  the  stomach 
secondary  to  gynecologic  dislocation  and  consequent  menorrhagia,  the  cure 
of  the  genital  disease  would  not  cure  the  round  ulcer  of  the  stomach,  which, 
if  it  bleed  profusely,  could  be  excised  from  the  stomach  wall,  i.  e.,  requires  a 
specific  treatment.  If  a  general  disease,  such  as  a  cardiac  valvular  lesion, 
create  genital  dislocation  through  congestion,  the  dislocation  may  produce 
reflex  neurosis,  but  cure  of  the  genital  lesion  does  not  involve  the  valvular 
lesion. 

The  logical  force  of  circumstances  impresses  the  practical  gynecologist 

341 


342  THE  ABDOMIXAL   AXD   PELVIC   BRAIX 

that  genital  disease  gradually  spreads  over  the  other  abdominal  and  thoracic 
viscera,  disturbing  visceral  rhythm,  circulation,  absorption,  secretion,  and 
sensation  by  means  of  arcs  of  reflex  action.  Step  by  step,  through  compro- 
mised circulation,  trauma  of  nerve  periphery  and  infection  of  the  genitals, 
the  woman  acquires  indigestion  due  to  perverted  secretion — excessive,  dispro- 
portionate, or  insufficient.  Malnutrition  and  anemia  follow  from  continued 
indigestion  and  finally  neurosis,  the  inevitable  consequence  of  progressive 
disturbed  pelvic  mechanism.  It  requires  careful  observation  to  discriminate 
the  onward  march  of  genital  disease,  since  many  complications  arise  to  throw 
one  off  guard,  such  as  lumbo-sacral  pain,  tenesmus  of  sphincters  (anus,  vagina, 
and  bladder),  hyperesthesia  of  the  pudendum,  tearing  and  dragging  pain  in 
the  thighs  (anterior  branches  of  lumbar  plexus),  pain  in  coccyx,  intercostal 
neuralgia,  especially  on  the  side  of  the  diseased  genitals,  pains  in  the  breasts 
and  irregular  muscular  contractions.  All  these  are  only  incidents  in  the 
onward  march  of  a  disease  of  dominating  viscera,  whose  reflexes  unbalance 
life's  physiologic  laboratory.  My  observation  places  70  per  cent  of  disturbed 
pelvic  mechanism  on  the  left  side;  however,  the  neurosis  shifts  from  side  to 
side  according  to  the  renewed  invasions  of  the  genitals  by  disease.  It  is 
significant  that  the  neurosis  falls  chiefly  on  the  side  of  the  disturbed  pelvic 
mechanism.  It  is  plain  that  the  genitals  have  quite  an  independent  nerve- 
supply  and  also  stand  in  intimate  relation  to  definite  regions;  in  other  words, 
diseased  genitals  have  a  predilection  for  certain  nerves  and  nerve  lesions. 
This  fact  is  patent  in  the  functional  crises,  at  puberty,  during  pregnancy,  at 
menstruation,  and  at  the  menopause.  In  pregnancy  the  irritation  from  the 
genitals  invades  the  stomach  in  a  physiologic  rather  than  the  pathologic 
degree.  The  grade  of  the  genital  irritation  of  pregnancy  and  menstruation 
seldom  reaches  a  pathologic  condition.  During  puberty,  menstruation, 
pregnancy,  and  the  menopause  certain  organs  suffer,  as  the  stomach,  breasts, 
larynx  and  thyroid  glands.  The  cranial  nerves  deserving  mention  for  a 
special  share  during  the  above  periods  are  the  trigeminus  and  vagus,  which 
may  manifest  not  only  excessive  physiologic  activity  but  an  actual  pathologic 
condition  (physiology).  The  lack  of  mathematical  demonstration  of  the 
share  of  the  viscera  and  nerves  in  the  above-mentioned  conditions  is  because 
this  sympathetic  disturbance  does  not  occur  in  ever}'  case.  The  close  relation 
existing  between  ovarian  disease  and  breast  and  iliac  pain  is  often  noted  by 
the  gynecologist,  as  well  as  dragging  pelvic  pain  and  stomach  disturbance 
in  retrodeviations  of  the  uterus.  The  significant  and  dominating  influence  of 
the  genitals  on  the  life  of  the  individual  is  manifest  by  the  exacerbation  of 
the  nervous  conditions  at  puberty,  menstruation,  pregnancy,  and  at  the  meno- 
pause, i.  e.,  at  the  sexual  crises.  If  the  genitals  are  healthy,  distinct  neuroses 
''functional)  at  the  above  phases  of  sexual  exacerbation  give  a  definite  clue 
to  the  source  of  the  nervousness.  No  other  viscera  except  the  genitals  pro- 
duce through  physiologic  activity  exacerbated  phases  of  neuroses.  The  sexual 
is  the  most  denominating  instinct  in  animal  life.  The  physiologic  exacerba- 
tion of  neuroses  is  the  most  definite  proof  of  their  source,  since  the  pathologic 
exacerbation  of  neuroses  is  so  complicated  that  errors  arise  in  tracing  the 


DYSMENORRHEA   MEMBRANACEA  343 

origin.  The  coincidence  of  neurosis  and  menstruation  induced  Battey  to  per- 
form castration  in  order  to  anticipate  the  menopause.  However,  it  is  my 
opinion  he  began  at  the  wrong  end  of  the  genitals,  for  nothing  stops  menstru- 
ation like  removal  of  the  chief  part  of  the  organ  of  menstruation,  viz. :  the 
uterus  (the  oviducts  may  be  left).  Menstruation  is  a  vascular  periodic  wave 
and  belongs  to  the  uterus  and  oviducts,  not  to  the  ovary.  Hence,  menstrual 
neuroses  are  cured  by  removal  of  the  menstrual  organ  and  not  by  removal  of 
the  ovary.  Considerable  worth  should  be  placed  on  certain  relations  between 
neuroses  and  special  phases  of  sexual  life.  It  may  be  suggested  that  these 
sexual  phases  of  exacerbation  belong  to  life  during  the  active  existence  of 
the  uterus  and  oviducts,  i.  e.,  or  the  menstrual  organs — not  during  the  active 
life  of  the  ovary,  for  activity  of  the  latter  persists  from  before  birth  until  the 
ovarian  tissue  is  worn  out  at  sixty  or  seventy  years.  It  is  an  error  to  per- 
form castration  because  the  menstrual  process  coincides  with  the  neurosis. 
In  such  a  case,  should  an  operation  be  performed,  it  ought  to  be  hysterectomy 
and  not  ovariotomy ;  the  organ  which  induced  the  neurosis  should  be  attacked. 
However,  it  is  simple  justice  to  the  patient  to  be  morally  sure  before  perform- 
ing any  operation  that  the  organ  to  be  attacked  is  the  definite  etiologic  cause, 
for  other  etiologic  factors  may  arise  to  unbalance  the  visceral  nerves  of 
woman;  a  stitch-abscess,  a  corn,  or  domestic  irritation  may  simulate  genital 
neurosis.  Extreme  precaution  is  required  in  diagnosing  the  neuroses  of  the 
sexual  organs.  This  fact  is  observed  from  the  varied  time  that  a  neurosis 
may  arise  during  menstruation.  Menstruation  is  a  complicated  process;  in 
other  words,  what  is  superficially  known  as  menstruation  is  perhaps  only  a 
part  of  a  comprehensive  physiologic  mechanism.  During  menstruation  we 
observe  swelling  of  the  mucosa  of  the  uterus  and  oviducts,  supposed  matura- 
tion and  rupture  of  follicles  (?),  and  various  degrees  of  congestion  of  the  pel- 
vic vessels  peculiar  to  the  wave  movements  or  vascular  pelvic  rhythm, 
indicating  blood-pressure.  Almost  any  of  the  above  factors  may  induce  a 
menstrual  neurosis,  as  the  neurosis  may  occur  in  the  premenstrual,  intramen- 
strual,  and  postmenstrual  period.  Some  neurotic  factors  may  be  displaced 
by  exacerbation,  and  neurosis  arises.  The  secretion,  blood,  may  occur  at, 
before,  or  after  the  highest  neural  menstrual  wave.  Menstruation  is  a  change 
of  symptoms  in  which  now  one  line  and  now  another  is  put  on  tension.  The 
tension  link  manifests  the  character  of  the  menstrual  neurosis.  Another 
factor  of  menstrual  chain,  as  accentuated  by  Kirro  (1878),  is  that  during  men- 
struation hypertrophy  of  the  thyroid  gland  occurs,  followed  by  passive  conges- 
tion of  the  cerebrum  and  consequent  psychosis.  Perhaps  hemorrhage  from 
the  nasal  mucosa  during  menstruation  is  from  congestion  due  to  the  sharing 
of  the  thyroid  in  menstruation  and  its  capacious  power  of  blood  storage. 
With  the  above  noted  complication  and  many  others  it  may  be  observed 
how  careful  the  physician  must  be  to  establish  menstrual  neuroses  or  psycho- 
sis. Continual  psychosis  can,  no  doubt,  be  exacerbated  by  the  menstrual 
periodicity;  also,  in  the  periodic  diseases  there  is  frequently  a  neuropathic 
constitution  that  results  from  congenital  defects  or  existing  pathology.  For 
example,  who  can  measure  the  burden  of  a  woman  with  non-development 


344  THE  ABDOMINAL  AND  PELVIC  BRAIN 

and  atrophy,  i.  e.,  before  the  uterus  was  fully  developed  it  was  attacked  by  in- 
flammation, producing  at  first  hypertrophy  and  ending  in  defective  growth  and 
atrophy?  Such  are  among  the  saddest  patients  in  my  practice.  They  suffer 
not  only  from  dysmenorrhoea  and  other  painful  neuroses,  but  from  a  psychosis 
due  to  inevitable  sterility.  Rachel  mourns  and  will  not  be  comforted. 
The  nervous  irritation  issuing  from  the  sexual  organs  may  be  from  disease 
or  change  of  blood-pressure;  in  other  words,  from  functional  or  anatomic 
changes.  In  neurotic  individuals  the  neurosis  exists  not  only  at  the  men- 
strual wave  but  also  in  the  intermenstrual  time,  when  pelvic  disease  is  liable 
to  exist.  When  a  certain  congruence  exists  between  the  neurosis  and  the 
menstrual  rhythm  it  is  a  strong  indication  that  the  neurosis  is  of  sexual  origin. 
Experimentally  the  congruence  of  neuroses  with  phases  of  the  sexual  organs 
is  demonstrated  by  the  disappearance  of  the  neuroses  after  hysterectomy  or 
correlation  of  the  uterus  and  uterine  deviations  or  the  destruction  of  pelvic 
peritoneal  adhesions  or  the  removal  of  a  pelvic  tumor.  Gynecologists  fre- 
quently note  that  a  neurosis  will  begin  with  anatomic  changes  of  the  sexual 
organs  and  the  neurosis  exacerbates  the  sexual  disease.  The  extent  and  the 
intensity  of  the  pathology  of  the  genitals  may  not  stand  in  definite  relation 
to  the  neurosis.  One  may  observe  large  ovarian  tumors  without  a  trace  of 
neurosis.  From  this  clinical  fact  some  have  falsely  argued  that  castration 
does  not  cure  neurosis  because  disease  of  the  ovaries  does  not  produce  it. 
There  are  factors  in  large  ovarian  tumors  which  explain  partly,  at  least,  why 
they  do  not  produce  a  neurosis.  First,  the  tumor  has  sufficient  room  to  glide 
out  of  the  way  of  pressure;  second,  the  style  is  sufficiently  long  to  avoid 
trauma  from  dragging  or  torsion  of  the  pedicle ;  and  doubtless  the  sensory 
nerves  which  supply  the  walls  of  the  ovarian  cyst  have  been  stretched  beyond 
their  integrity  and  have  ceased  to  transmit  sensory  disturbances.  It  is  the 
small  genital  tumors  located  in  the  pelvis  which  are  likely  to  be  accompanied 
by  neurosis.  Such  small  tumors  have  a  short  style  and  are  liable  to  dragging 
and  torsion.  They  are  subject  to  pressure  from  their  immobility.  The  filling 
of  the  bladder  and  rectum  traumatizes  them  and  frequently  a  neurosis  and  a 
small  pelvic  tumor  exist  in  casual  relations.  The  life  and  action  of  nerves 
cannot  be  measured  by  the  yard.  Extreme  neurosis  may  arise  from  the  geni- 
tals by  an  irritation  of  the  clitoris,  a  slight  uterine  deviation  or  a  small  scar, 
while  no  neurosis  may  be  detected  from  extension,  of  sarcoma  or  carcinoma 
of  the  uterus  or  large  ovarian  tumor.  Abdominal  or  pelvic  tumors  that  give 
rise  to  a  tendency  to  neurosis  are  generally  from  small,  fixed  growths  (espe- 
cially located  in  the  pelvis)  with  short  pedicles,  situated  within  the  range  of 
trauma  by  muscular  activity  and  by  the  expansion  and  contraction  of  organs. 
The  excitation  or  the  inhibition  of  nervous  attacks  by  artificial  irritation 
is  known  to  gynecologists.  Mechanical  irritation  of  other  viscera  seldom  or 
never  creates  a  nervous  attack.  This  experiment  indicates  that  the  capacity 
of  the  genitals  to  dominate  the  nervous  system  is  greater  than  that  of  other 
viscera.  I  was  called  in  consultation  in  a  typical  case — a  young  woman  in 
whom  slight  pressure  in  the  ovarian  region  induced  a  wild  hysteric  attack, 
while  vigorous  pressure  would  inhibit  it.     Such  cases,  not  rare,  are  a  close 


SECRETION   XliUROSIS  IN  MUCOUS  MEM  BRAS  E  345 

demonstration  of  the  dominating  influence  of  the  genitals  over  the  system 
and  also  of  the  origin  of  the  neurosis.  To  show  how  carefully  one  must  dis- 
criminate the  sources  and  kind  of  neurosis,  a  case  from  Professor  Hegar  may 
be  placed  in  evidence.  She  was  a  young,  non-neurotic  individual  who  had  a 
fist-sized  right  ovarian  tumor  with  a  long  style,  which  allowed  extraordinary 
mobility;  when  the  tumor  glided  into  the  pelvis  she  suffered  from  pressure 
and  dragging  sensations.  She  complained  daily  of  dragging  on  the  pedicle, 
pains  in  the  lumbo-sacral  region,  shoulder,  and  iliac  region.  To  be  relieved 
from  these  tormenting  pains  she  besought  Professor  Hegar  to  operate  on  her. 
She  was  without  fever  or  pain  for  the  first  nine  days — well  and  happy.  On 
the  tenth  day  she  was  found  with  tears  and  sorrow,  claiming  that  all  her 
former  troubles  had  returned,  and  all  embittered  because  the  operation  had 
not  relieved  her.  The  neuralgia,  the  cramps,  the  pressure,  dragging  symp- 
toms, etc.,  all  had  returned  back.  Professor  Hegar  noted  that  the  patient 
had  fever  and,  on  examining  the  abdominal  incision,  discovered  a  stitch 
abscess;  this  was  opened  and  the  pains  disappeared  and  returned  no  more. 
This  was  a  suggestive  case,  confirming  the  rule  that  when  a  subject  is  neu- 
rotic for  a  long  time  any  bodily  irritation  may  be  set  going  the  old  train  of 
neurotic  symptoms.  In  other  words,  a  primary,  complex  neurosis,  long  con- 
tinued, may  be  initiated  by  some  distant  local  irritation.  The  secondary 
cause  may  be  slight,  such  as  a  fright,  an  abscess,  an  injury,  a  disappointment 
or  an  exacerbation  of  disturbances  in  a  menstruation.  Doubtless,  in  the 
long  continued  neurosis  a  disturbed  mechanism  arises  in  the  nerves,  they  lose 
their  fine  balance  of  integrity  in  motion,  absorption,  secretion,  or  sensation, 
and,  being  in  a  state  of  irritability,  they  are  put  to  riot  by  any  source  of 
attack.  It  is  in  such  unfortunate  cases  that  the  neurologist  has  lost  sight  of 
the  primary  cause,  which  was  trauma  and  infection  of  the  genital  system,  the 
dominating  neurovascular  viscera.  For  example,  those  who  have  much 
toothache  know  that  any  disturbance  in  health,  as  colds,  getting  wet,  etc., 
will  finally  end  in  the  old  disease  of  toothache.  The  dental  nerves  having 
once  become  chronically  unbalanced  by  trauma  and  infection,  it  is  easy  to 
light  the  old  flame  again.  Observe  the  man  who  is  suffering  the  remote 
effects  of  an  ancient  gonorrhea,  the  stricture  fires  up  with  a  cold,  an  extra 
drink  of  whiskey  or  slight  excess  in  coition.  The  old  flame  in  the  disturbed 
urethral  mechanism  may  be  initiated  by  remote  secondary  causes.  The  geni- 
tals are  defective  and  do  not  resist.  Demonstrations,  by  experiment,  can  be 
made  to  show  that  the  neurosis  depends  on  the  genital  disease.  The  reposi- 
tion and  retention  of  a  dislocated  or  incarcerated  pregnant  uterus  is  frequently 
accompanied  by  a  disappearance  of  the  neurosis,  while  paresis  of  the  lower 
limbs  or  uterine  cough  allows  the  pathology  to  recur  and  the  neurosis  is  again 
set  afoot.  Paint  the  cervix  with  AgN03  solution  and  vicious  vomiting 
follows.  No  doubt  can  arise  as  to  the  cause  of  the  vomiting.  But  the  ter- 
rific vomiting  would  not  occur  by  painting  other  viscera  not  so  richly  supplied 
with  nerves,  such  as  the  rectum  or  larynx.  Professor  Hegar  had  a  case  where 
he  could  repeatedly  check  a  "uterine  cough"  or  irritable  cough  by  introducing 
a  intra-uterine  stem  which  straightened  an  anteflexed  uterus.     In  the  am- 


346  THE  ABDOMINAL   AND   PELVIC   BRAIX 

phibia.  in  dissecting-  animals  that  require  a  day  to  die,  one  can  demonstrate 
ocularly  that  irritating  the  rectum,  cloaca,  will  start  muscular  contractions 
about  the  stomach.  Doubtless  the  irritation  to  the  sensory,  absorptive  and 
secreting  nerves  is  just  as  severe  but  is  not  so  easily  seen.  But  every  gynecol- 
ogist knows  that  some  women  with  disturbed  pelvic  mechanism  suffer  from 
exacerbated  stomach  secretion  and  motion.  It  is  important  to  demonstrate 
the  causal  relations  and  establish  the  location  at  the  beginning.  This  is  diffi- 
cult from  the  complex,  yet  somewhat  independent,  sexual  nervous  apparatus 
that  gives  rise  to  the  neurosis,  from  the  peculiarly  highly  organized  nervous 
system  of  women  and  from  the  further  fact  that  reflex  neuroses  are  quite 
indirect  and  slow  in  their  progressive  march.  The  original  cause  which  may 
be  years  old  is  overlooked  in  the  exciting  symptoms.  It  is  not  difficult  to 
connect  a  fresh  anal  fissure  with  its  accompanying  wild  disturbance,  but  when 
the  disturbed  pelvic  mechanism  (the  anus  and  bladder  have  intimate  nerve 
connection  with  the  genitals)  progresses  for  long  periods  the  cause  is  buried 
in  the  grave  of  years  gone  by.  Long  experience  in  digital  examination  is  the 
prerequisite  for  accurate  diagnosis  of  disturbed  pelvic  mechanism  and  for  the 
interpretation  of  its  reflex  effect.  The  disturbed  pelvic  mechanism,  the 
primary  cause  of  sexual  neurosis,  begins  from  simple  disturbances  in  the  geni- 
tals, such  as  pressure  or  dragging  of  nerves.  These  two  conditions  may  be 
combined  and  we  cannot  always  discriminate  one  from  the  other.  For 
example,  in  the  frequent  vomiting  of  early  pregnancy  it  is  impossible  to  say 
whether  it  is  pressure  dragging  upon  the  vesical  or  uterine  distension  nerves 
that  induces  uterine  contractions  and  is  followed  by  vomiting.  After  drag- 
ging or  pressure  (trauma)  of  nerves  has  become  initiated  another  more 
distressing  trauma  of  the  genital  nerves  follows  from  catarrh,  erosions,  ulcer- 
ations, and  wounds  which  expose  the  periphery  of  the  nerves — all  inducing 
reflexes  which  radiate  to  other  viscera,  unbalancing  their  rhythm,  secretion, 
absorption  and  sensation.  The  compression  (trauma)  of  the  nerve  periphery 
arises  from  dislocation  of  organs,  edema,  exudate,  or  tumor  pressure.  Such 
traumatic  (compression)  neurosis  is  common  in  gynecology. 

Compression  of  the  periphery  of  the  nerves  may  be  due  to  cicatricial  tis- 
sue of  both  the  pelvic  peritoneum  and  subserosium.  Rich  sources  of  nerve 
compression  may  be  found  in  the  inflamed  posterior  and  lateral  ligaments  of 
the  uterus,  as  shown  by  Freund  and  others.  The  hyperplastic  deposits  and 
subsequent  contraction  found  in  the  uterus,  ovaries,  and  connective  tissue 
needs  but  be  mentioned  to  be  rocognized.  The  contracting  tissue  of  the 
uterus  painfully  compromises  its  expansion  at  the  monthly  period  and  the 
excessive  ovarian  cicatrices  obstruct  the  expanding  ovum  and  induce  painful 
reflexes.  The  type  of  dragging  (traumatic)  neurosis  is  observed  in  sacropubic 
hernia  or  uterine  prolapse  and  in  retrodeviations  of  the  uterus,  the  visceral 
prolapse  gradually  developing  a  complex  neurosis  of  the  lumbosacral  region 
and  thence  spreading  to  unbalance  the  general  abdominal  viscera  through 
reflexes  of  the  abdominal  brain.  Dragging  on  the  style  of  pelvic  tumors  is 
another  cause.  One  may  be  able  to  measure,  to  some  extent,  the  disturbance 
of  dragging  on  nerves,  on  over-filled  rectum  or  bladder.     I  have  seen  the  pel- 


NEUROSIS  FROM  DISTURBED   VISCERA  347 

vis,  at  autopsy,  full  to  the  brim  with  fecea  The  dragging  of  free  tumors  on 
styles  must  be  considerable,  for  strangulated  axial  rotation  is  not  infrequent. 
The  best  illustration  of  suffering  from  a  free  tumor  on  its  style  is  the  right 
kidney.  Its  dragging  and  rotation  give  rise  to  nausea,  vomiting,  pain  in  the 
back  and  thigh;  excessive,  insufficient  or  disproportionate  secretion  or  absorp- 
tion in  the  tractus  intestinalis,  inducing  disturbances  of  digestion,  and  to 
similar  disorders  in  the  renal  secretion. 

Compression  neurosis  is  indelibly  associated  with  dragging  neurosis. 
With  inflamed  peritoneal  and  subserous  uterine  ligaments  reflex  symptoms 
occur  on  standing,  walking,  and  coughing.  The  reposition  of  the  pelvic 
organs  and  their  retention  by  a  support  relieves  the  symptoms.  The  cicatrices 
of  the  cervix  and  vagina  may  present  compression  or  dragging  neurosis,  often 
accompanied,  however,  by  endometritis,  with  exposed  nerve  endings,  on 
which  play  visceral  secretions.  In  acute  flexions  connective  tissue  changes 
cause  pinching  of  the  peripheral  nerves,  which  manifest  the  neurosis  chiefly 
as  dysmenorrhea.  In  endometritis  with  exposed  nerve  periphery  the  irritat- 
ing secretions  induce  painful  uterine  colic,  calling  up  reflexes  which  reorganize 
in  the  abdominal  brain  and  radiate  to  all  abdominal  and  thoracic  viscera, 
vitiating  rhythm,  secretion,  and  sensation.  From  the  swollen  endometrium 
the  uterine  contractions  are  futile  to  expel  the  secretions.  The  uterine  con- 
tractions produce  pain  by  compression  of  the  nerves  imbedded  in  diseased 
tissue.  The  gynecologist  has  a  typical  case  to  show  the  traumatic  neurosis 
of  nerves  compressed  in  exudates  in  the  old  operations  of  amputation  of  the 
oviduct  and  ligation  with  silk,  where  the  silk  ligature  becomes  infected  from 
diseased  oviductal  mucosa  and  an  exudate  arises  with  monthly  exacerbations. 
It  is  not  uncommon  for  such  cases  to  last  for  three  years,  with  terrible  com- 
plex neurosis  and  untold  misery.  Hysterectomy  cures  such  cases  by  stopping 
menstruation  and  relapses.  If  the  uterus  and  bladder  become  imbedded  in 
exudates  their  expansion  and  also  that  of  the  rectum  is  hindered,  and  severe 
reflex  pains  follow.  Collection  of  secretions  in  the  uterus  induces  contrac- 
tion to  expel  them,  and  in  contracting,  the  uterus  drags  on  the  adjacent  fixed 
exudates.  All  motion  of  the  uterus,  bladder,  and  rectum  is  accompanied  by 
compression  or  dragging  pains — neurosis  from  trauma.  In  connective  tissue 
hyperplasia  of  the  uterus  the  uterine  contractions  are  often  very  painful  for 
compression  of  the  nerves  imbedded  in  the  cicatrizing  tissue.  In  myosalpin- 
gitis  may  be  observed  the  recurring  monthly  exacerbations,  the  old  train  of 
neurosis  from  the  oviductal  colic,  from  congestion,  contraction,  or  compres- 
sion; lumbosacral  neuralgia,  however,  the  associated  uterine  congestion  from 
adjacent  disease,  must  not  be  overlooked.  In  some  cases  I  have  noted 
terrible  neurotic  symptoms  from  the  amputated  end  of  the  oviduct  being  con- 
nected to  a  loop  of  a  sigmoid  by  a  peritoneal  band.  In  one  case  in  which 
Dr.  Lucy  Waite  and  I  operated  we  found  a  thin  peritoneal  band  extending 
from  the  amputated  oviductal  extremity  to  the  center  of  the  sigmoid  flexure; 
this  woman  was  bedridden  for  nearly  two  years  with  the  most  terrible  neurosis. 
The  severing  of  the  thin  peritoneal  band  enabled  her  to  recover  and  gain 
some  thirty  pounds  six  months  after  the  operation,  with  apparent  perfect 


348  THE  ABDOMINAL   AND   PELVIC   BRAIN 

health.  Her  neurosis  disappeared  like  magic.  Peritoneal  adhesions  may 
bind  the  intestines  and  genitals  together.  Irritation  of  either  the  genitals  or 
intestines  influence  peristalsis,  and  dragging  pain  and  intense  neurotic  symp- 
toms often  follow  in  the  wake.  Visceral  secretions  and  sensations  are  per- 
verted. In  such  cases  disturbances  are  after  mealtimes  and  evacuations, 
and  are  caused  by  the  induced  peristalsis  traumatizing  nerves,  imbedded  in 
exudates  and  congesting  vessels.  In  some  young  women  following  castra- 
tion and  in  some  others  following  the  menopause,  the  pudendum  and  vagina 
atrophy.  This  doubtless  is  consequent  upon  vaginitis  and  atrophy  of  blood- 
vessels. The  vessels  atrophy  irregularly  (one  can  observe  red,  injected 
patches  among  the  pale  ones  on  the  vaginal  wall)  and  this  irregularity  causes 
local  congestions.  In  cases  of  vaginal  atrophy  coitus  enhances  the  neurosis 
on  account  of  the  narrow  and  sensitive  vagina,  and  a  kind  of  vaginismus 
occurs. 

Nervous  irritation  may  be  occasioned  by  exposure  of  the  genital  nerve 
periphery  from  vaginal  catarrh,  papillary  swellings  at  the  vaginal  introitus, 
or  the  meatus  urinarius  externus,  or  from  fissures  or  erosions  about  the 
urethra,  pudendum,  or  anus.  Such  lesions  are  often  exacerbation  by  urina- 
tion, defecation,  coitus,  or  scratching,  and  may  be  accompanied  by  severe 
neurosis  if  allowed  to  persist  for  a  long  time.  Progressive  nervous  affections 
rapidly  radiate  from  the  local  lesion  to  the  general  visceral  system.  The  irri- 
tation may  remain  isolated  in  the  nervous  system  of  the  genitals  for  a  longer 
or  shorter  period,  but  if  long-continued  or  severe  the  neurosis  eventually 
spreads  to  the  general  nervous  system  and  is  followed  by  indigestion,  consti- 
pation, sleeplessness,  and  a  state  of  more  or  less  high  nerve  tension;  in  other 
words,  a  peculiar  nervous  irritability.  Entirely  isolated  neuroses  from  the 
genitals  are  quite  rare  because  the  nervous  apparatus  of  the  genitals  is  so 
intimately  and  profoundly  connected  with  both  the  cerebrospinal  and  the 
great  sympathetic  systems  that  disturbance  in  the  rich  nerves  of  the  genitals 
spreads  over  the  whole  nervous  system. 

Besides,  the  disturbed  pelvic  mechanism  often  sooner  or  later  invades 
the  psychical  apparatus  and  directs  the  mind  to  the  diseased  genitals  with 
additional  disadvantage  to  the  individual.  The  general  practitioner  is  very 
liable  to  treat  the  psychical  or  mental  symptoms,  forgetting  that  the  disturbed 
pelvic  mechanism  is  the  rock  and  base  of  the  neurosis.  Not  infrequently  the 
psychical  symptoms  play  the  chief  role  in  the  disease.  How  often  does  the 
gynecologist  observe  the  general  practitioner  treating  the  psychical  or  super- 
ficial symptoms — cardialgia,  sacrolumbar  neuralgia,  or  sexual  disease  with 
little  idea  of  its  etiology — though  palpable  in  the  pelvis?  In  short,  the  psy- 
chosis, which  has  a  mental  base,  and  the  neurosis,  which  has  a  physical  base, 
should  be  carefully  differentiated.  However,  the  psychosis  is  generally  sec- 
ondary to  the  neurosis,  which  latter  generally  has  a  palpable  pelvic  origin. 
It  is  what  I  shall  term  a  vicious  sexual  circle,  viz. :  (a)  disturbed  pelvic 
mechanism,  (b)  neurosis,  and  (c)  psychosis.  This  is  accentuated  in  other 
ways  by  Hegar,  Freund,  Krantz  and  others  to  whose  excellent  labors  I  am  a 
debtor.     More  in  detail,  this  vicious  sexual  circle  consists  of  (a)  disturbed 


NEUROSIS  FROM  DISTURBED   VISCERA  349 

pelvic  mechanism  (trauma  and  infection) ;  (b)  indigestion  (from  disturbed 
visceral  motion,  secretion,  absorption,  and  sensation);  (c)  malnutrition;  (d) 
anemia;  (e)  neurosis,  and  (f)  psychosis.  From  the  disturbed  pelvic  mechan- 
ism to  the  psychosis  is  a  long  progressive  march,  a  vicious  sexual  circle, 
direct  and  indirect,  due  to  repeated  reflex  pelvic  storms  flashing  over  the  other 
abdominal  visceral  plexuses.  The  viscera  (as  the  stomach,  kidney,  and  liver) 
possessing  the  greatest  number  of  connective  nerve-cords  and  hence,  the  least 
resistance,  will  suffer  the  most  in  their  rhythm,  secretion,  and  sensation. 
After  this  vicious  sexual  circle  becomes  established  there  exists  a  neuropathic 
condition.  Primary  and  secondary  symptoms  then  become  difficult  of  differ- 
entiation. Direct  and  indirect  symptoms  become  mixed  and  the  clinical  pic- 
ture becomes  obscured  by  its  complexity.  The  causal  connection  between 
pelvic  disease  and  neurosis  (psychosis)  becomes  darkened  and  one  cannot  tell 
what  is  primary  and  what  is  secondary,  especially  when  the  patient  comes  to 
the  physician  late  in  the  course  of  the  malady.  It  is  difficult  to  pick  up  any 
segment  of  the  vicious  sexual  circle.  Action  and  reaction  are  equal.  We 
now  have  the  degenerating  influence  of  the  general  nervous  system  on  the 
original  disturbed  pelvic  mechanism.  In  the  vicious  sexual  circle  one  should 
never  disregard  blood  losses,  as  these  often  play  a  significant  role.  An  or- 
dinary monthly  period  makes  women  pale  and,  if  slight  additional  losses  occur, 
the  effect  is  geometrically  exacerbated.  Excessive,  deficient,  or  disproportion- 
ate blood  supply  to  the  abdominal  brain  and  its  automatic  visceral  ganglia 
due  to  reflexes,  deranges  visceral  motion,  secretion,  absorption,  and  sensation. 
It  would  create  in  single  viscera  local  disorderly  reflexes.  Aside  from  the 
vicious  sexual  circle  I  know  of  no  experimental  method  to  demonstrate  it, 
except  the  disease  itself,  which  gynecologists  see  daily.  We  must,  as  Hegar 
observes,  be  limited  to  the  indexes  of  its  course  in  order  to  diagnose  and 
treat  it.  We  must  weigh  each  indication  found  in  the  progressive  march  of 
symptoms  throughout  the  vicious  sexual  circle  from  genital  disease.  We 
must  have  definite  stigmata  to  diagnose  hysteria  and  not  call  every  nervous 
woman  a  hysteric.  The  exclusion  method  must  be  employed  for  each  and 
every  diagnosis,  and  the  treatment  must  include  medical,  electrical,  surgical, 
and  hydrotherapeutic  measures  as  required.  Treatment  is  experimental  but 
should  be  rational.  The  rational  diagnosis  is  to  first  establish  some  etiologic 
pathologic  factor,  and  attempt  to  improve  or  remove  it.  Sometimes  a  second- 
ary factor,  as  constipation  or  gastric  disease,  requires  attention  in  order  to 
trace  our  steps  to  the  original  pelvic  disease.  We  must  attempt  to  retrace 
on  the  links  of  the  causal  chain  to  the  swivel  where  the  reflexes  began  and 
broke  their  bounds.  Deficient  renal  secretion  may  be  another  secondary 
symptom  which  requires  improvement  before  the  waste-laden  61ood  will  cease 
traumatizing  the  innumerable  ganglia  which  it  bathes. 

In  the  diagnosis  one  must  observe  local  diseases  in  the  body  which  are 
not  of  sexual  origin.  The  sexual  organs  are  not  the  only  viscera  capable  of 
producing  neurosis.  Be  always  on  the  alert  for  visceral  ptosis,  tuberculosis, 
nephritis,  cholecystitis,  peritonitis,  and  appendicitis.  Of  course,  the  non- 
sexual diseases  may  be  coincident  with  sexual  diseases,  and  both  influence  the 


350  THE  ABDOMINAL  AND   PELVIC  BRAIN 

neurosis  and  general  nourishment.  Make  careful  bodily  examinations  for 
diseases  outside  the  genitals.  Do  not  overlook  heart  lesions  which  allow  con- 
gestions, hepatic  sclerosis  which  induces  some  ascites,  chlorosis  which  induces 
general  paleness,  with  a  large  glandular  system,  yet  coexists  with  a  well-de- 
veloped panniculus  adiposus,  headaches,  and  breathlessness,  anemia,  etc.,  etc. 
In  my  experience  nothing  has  been  so  successful  as  visceral  drainage — draining 
the  skin  by  salt  baths,  the  kidneys  by  drinking  ample  fluids,  and  the  bowels 
by  salines,  with  set  hour  for  evacuation.  Drainage  of  the  bowels,  skin,  and 
kidneys  is  the  rock  and  base  of  the  therapeutics  which  will  benefit  the  vicious 
sexual  circle.  It  is  rational  hydrotherapy.  Thus,  by  treatment,  we  are 
often  enabled  to  run  over  one  difficulty  after  another  until  the  etiologic  factor 
is  reached,  which  is  disturbed  pelvic  mechanism,  the  beginning  of  the  viscious 
sexual  circle.  In  other  words,  the  microscope  aids  to  diagnose  tuberculosis, 
or  mercury  to  diagnose  syphilis.  In  diagnosis  and  treatment  the  gynecologist 
must  always  hold  in  his  mental  grasp  every  abdominal  organ. 

With  the  entrance  and  establishment  of  the  neurosis  and  psychosis  the 
sexual  pathologic  circle  is  completed  and  persistent  rational  treatment  is 
required  to  break  it.  Now,  any  segment  of  the  pathologic  circle  has  a  degen- 
erating influence  on  the  others.  Pathologic  processes  can  arise  in  other  por- 
tions of  the  body,  either  coincident,  independent,  or  as  a  result  of  the 
pathologic  sexual  circle.  The  gynecologist  not  only  should  have  every 
abdominal  organ  in  mind  but  should  be  able  to  exclude  all  other  pathologic 
processes.  Among  the  abdominal  organs  requiring  special  care  in  diagnosis 
are  the  stomach  and  colon.  Stomach  and  colon  diseases  may  lead  to  reflexes, 
hypochondria,  neurosis,  and  even  psychosis.  Note  what  intense  neurosis  fol- 
lows secretion  neurosis  of  the  colon  (mucous  colitis) ;  also,  that  slackening  or 
paresis  of  the  abdominal  wall — splanchnoptosia — accompanied  by  visceral  pto- 
sis and  dragging  on  the  mesentery,  can  lead  to  lumbosacral  symptoms.  For 
example,  for  years  I  have  noted  the  hyperplasia  of  the  genitals  and  hemor- 
rhage therefrom  in'  mitral  lesions  of  the  heart.  In  this  case  the  heart  disease 
is  primary  and  the  pelvic  disease  secondary.  The  genitals  show  varicose 
veins  and  the  pelvic  disease  and  hemorrhage  may  become  so  severe  that  a 
neurosis  results.  In  this  neurosis  the  diseased  genitals  were  only  a  link  in 
the  chain. 

Of  course,  these  conditions — variously  known  as  neurasthenia,  neurosis, 
spinal  iritation,  or  hysteria — may  exist  without  palpable  sexual  disease,  but 
any  gynecologist  knows  that  sexual  disease  plays  an  important  factor  and 
often  enters  in  combination  in  their  production. 

Bibliography:  Professor  Hegar,  Lohmer,  Krantz. 


CHAPTER   XXIX. 

CONSTIPATION— ITS    PATHOLOGIC    PHYSIOLOGY    AND  TREAT- 
MENT BY  EXERCISE,   HABITAT,   DIET  AND  "VISCERAL 

DRAINAGE." 

"Noiv  is  the  winter  of  our  discontent  made   glorious   summer  by  this  sun  of 
York" —Shakespeare  in  Richard  III. 

"Literature  is  the  immortality  of  speech." — Schlcgel. 

Constipation  is  infrequent  or  incomplete  evacuation  of  the  colon  result- 
ing in  fecal  retention. 

ETIOLOGY  OF  CONSTIPATION. 

The  etiology  of  constipation  is  obscure.  One  writer  alone  offers  some 
score  of  causes.  Sluggishness  of  the  bowel,  whatever  that  means,  is  the 
most  frequently  mentioned.  The  tractus  intestinalis  is  practically  under  the 
domain  of  the  sympathetic  nerve,  nervus  vasomotorius.  Certain  general 
etiologic  conditions  may  be  considered: 

/.  Physiology  of  the  tractus  intestinalis.  In  the  etiology  of  constipa- 
tion four  physiologic  factors  are  involved,  viz.,  (a)  peristalsis,  (b)  absorp- 
tion, (c)  secretion,  (d)  sensation.  Any  one  or  all  of  these  functions  may  be 
impaired. 

II.  Local  Causes. — The  local  causes  of  constipation  may  be:  (1)  splanch- 
noptosia — inefficient  muscular  contraction;  (2)  constriction  of  some  segment 
of  the  colon ;  (3)  collections  of  scybola  or  intestinal  concretions,  as  in  cecum, 
sigmoid  and  rectum;  (4)  enfeebled  contraction  of  the  intestinal  muscularis; 
(5)  local  disease,  as  appendicitis,  cholecystitis,  pelvic  peritonitis  mesosig- 
moiditis — producing  paresis. 

III.  General  Causes. — The  general  causes  of  constipation  are:  (1)  ineffi- 
cient function  (peristalsis,  absorption,  secretion,  sensation) ;  (2)  excessive 
mental  or  physical  activity;-  (3)  special  habits;  (4)  dietetic  errors ;  (5)  diseases 
of  adjacent  viscera;  (6)  factors  which  induce  dryness  of  feces  from  inefficient 
secretion  or  excessive  absorption ;  (7)  impaired  peristalsis  of  the  colon. 

IV.  Anatomy. — The  proper  function  of  the  tractus  intestinalis  depends 
on  a  normal  nerve,  blood  and  lymph  apparatus.  For  perfect  physiology,  a 
maximum  nerve,  blood  and  lymph  supply  is  required.  The  muscularis  intes- 
tinalis, as  well  as  the  mucosa  intestinalis,  must  be  perfect.  From  frequent 
diseases  (catarrh)  of  pueritas  and  consequent  defective  digestion,  with  result- 
ing deficient  nourishment,  a  non-developed  and  defective  tractus  intestinalis 
remains  for  life. 

Atrophic  or  infantile  segments  of  the  digestive  tract  (especially  the 
enteron  or  small  intestine,  which  is  the  essential  segment — receiving  the  secre- 

351 


352  THE  ABDOMINAL  AXD  PELVIC  BRAIS 

tions  from  liver  and  pancreas)  burden  the  adult.  For  example,  I  found  in 
the  personal  measurements  of  the  enteron  in  six  hundred  and  five  adults  that 
the  length  of  the  enteron  was,  maximum,  thirty-two  feet ;  minimum,  ten  and 
one-half  feet,  and  average,  twenty-one  feet.  The  enteron  (a  single  segment 
and  the  most  essential  one),  the  business  portion  of  the  digestive  tract,  varies 
more  than  three  times  its  minimum  length.  These  facts  demonstrate  that 
the  tractus  intestinalis  is  frequently  defective  in  length,  in  development, 
nerve,  blood  and  lymph — in  anatomy.  Abnormally  diminutive  digestive 
apparatus  may  occur.  The  following  recorded  data  secured  by  the  personal 
examination  of  six  hundred  and  five  adults,  may  be  suggestive  in  regard  to 
the  anatomy  of  the  tractus  intestinalis: 

1.  The  average  length  of  the  enteron  in  four  hundred  and  fifty-three 
males  was  twenty-three  feet. 

2.  The  average  length  of  the  enteron  in  one  hundred  and  fifty-two 
females  was  nineteen  feet. 

3.  Man's  enteron  averages  four  feet  longer  than  that  of  woman. 

4.  The  enteron  increases  in  length  most  rapidly  a  few  months  subsequent 
to  birth,  when  it  may  grow  one  and  one-half  feet  a  month. 

5.  The  enteron  assumes  its  chief  length  in  early  childhood. 

6.  The  chief  variation  in  the  length  of  the  enteron  depends  on  enteritis, 
compromising  the  enteronic  peristalsis,  absorption,  secretion,  and  sensation, 
and  consequently  digestion,  during  early  extrauterine  life. 

7.  Extraordinary  lengths  of  the  enteron  depend  on  the  favorable  condi- 
tions of  a  maximum  enteronic  nerve  and  vascular  supply,  with  maximum 
assimilation  continued  beyond  the  usual  period  of  enteronic  development. 

8.  A  subject  with  maximum  length  of  enteron  possesses  a  stronger  con- 
stitution than  a  subject  with  minimum  length,  as  he  can  digest  and  economize 
more  food. 

9.  A  maximum  enteronic,  nerve,  vascular,  glandular,  and  muscular 
apparatus,  with  similar  food,  would  practically  produce  a  similar  length  of 
enteron. 

10.  The  foods  which  produce  the  most  vigorous  enteronic  functions 
(peristalsis,  absorption,  sensation,  and  secretion)  are  those  that  leave  the 
greatest  indigestible  fecal  residue,  which  excites  the  enteronic  muscularis  into 
peristalsis,  thus  attracting  more  blood  and  inciting  the  enteronic  mucosa  to 
greater  secretion  and  absorption — increasing  digestion  and,  consequently, 
enteronic  growth. 

11.  General  and  local  disease  influence  the  length  of  the  enteron, 
especially  during  childhood,  the  period  in  life  of  rapid  enteronic  growth. 

12.  A  child  nourished  with  food  which  requires  vigorous  digestion, 
leaves  a  fecal  indigestible  residue,  as  cereals,  would  attract  more  blood  to 
the  enteron,  enhancing  its  growth,  than  one  nourished  on  milk  only,  which 
passes  through  the  enteron  without  inducing  vigorous  peristalsis,  and  leaves 
little  indigestible  residue. 

13.  The  human  enteron  presents  colossal  differences  as  to  length:  Males 
ll/^  feet  minimum,  32  feet  maximum  =  20  feet;  female  105^  feet  minimum 


DIETETIC  QUALITIES  OF  FOOD  353 

feet,  30  feet  maximum  =  19/4  feet.  This  variation  of  twenty  feet  is  almost 
equal  to  the  length  of  an  average  enteron.  The  enteron  varies  over  double, 
or  two  and  one-half  times  its  length. 

14.  In  adults  the  relation  of  the  length  of  the  enteron  to  the  body  length 
is  as  7.2  is  to  1.  There  is  a  vast  difference  between  the  absolute  and  relative 
length  of  the  enteron  of  man. 

15.  The  enteron  measured  in  situ  is  three  to  six  feet  less  in  length  than 
when  extirpated. 

16.  Different  diseases  of  the  enteron  may  result  in  elongation  or  contrac- 
tion. The  above  defects  are  not  heredity,  but  acquired  by  disease.  They 
will  offer  a  clew  to  conditions  for  constipations. 

V.  Mechanical. — Constipation  may  arise  from  stricture,  flexions,  perito- 
neal adhesions,  neoplasm,  splanchnoptosia,  obstruction  of  lumen. 

VI.  Dietetic. — Quality  of  foods,  quantify  of  fluid,  chemical  composition, 
are  important  considerations.  (a)  Food  must  possess  sufficient  variety 
(mixed)  in  quantity,  quality,  chemical  composition,  and  be  ingested  at  regular 
intervals.  The  food  should  be  mixed,  however,  and  possess  sufficient  indi- 
gestible matter  to  leave  ample  residue  to  stimulate  peristalsis  (and  hence 
absorption,  sensation,  and  secretion).  An  excessive  amount  of  coarse,  indi- 
gestible food  will  result  in  an  excessive  fecal  residue,  which  excessively 
stimulates  peristalsis,  absorption,  secretion  and  sensation — resulting  in  mus- 
cular fatigue  and  defective  sensibility  of  the  mucosa — consequently  reflex 
action  is  impaired,  (b)  Ample  fluids  at  regular  intervals  should  be  ingested. 
For  a  person  of  one  hundred  and  fifty  pounds  three  pints  daily  is  required  to 
supply  the  bodily  waste  (i.  e.,  for  tractus  intestinalis  respiratorius,  urinarius, 
perspiratorius) ;  eight  ounces  should  be  drunk  every  two  hours  for  six  times 
daily. 

Fecal  matter  is  about  seventy-five  per  cent  fluid  and  twenty-five  per  cent 
solid.  The  value  of  fluids  for  the  tractus  intestinalis  is  evident,  because  in 
hot  weather,  with  consequent  vigorous  activity  of  the  tractus  respiratorius, 
constipation  results.  The  chief  value  of  mineral  water  is  the  quantity  drunk. 
Excessive  fluids  deteriorate  digestion;  (c)  foods  should  possess  chemical 
qualities.  Carbohydrates  produce  acidity,  nitrogenous  foods  alkalinity,  and 
mixed  foods  neutrality  of  the  digestive  tract.  Evacuation  of  the  tractus 
intestinalis  depends  on  (a)  sufficient  volume  of  feces,  (b)  sufficient  volume  of 
fluid  contents,  (c)  the  presence  of  substances  which  act  as  a  chemical 
irritant  to  peristalsis.  Dr.  Walter  Baumgarten  attempted  to  devise  a  sub- 
stance which  would  not  only  be  difficult  to  absorb,  but  would  retain  its 
watery  contents.  He  adminstered  eight  grains  of  the  dry,  shredded  agar-agar 
three  times  daily,  whence  he  found  the  stool  increased  in  volume  and  watery 
content. 

VII.  Pathologic. — The  pathologic  impairment  of  peristalsis,  secretion, 
absorption,  and  sensation  of  the  tractus  intestinalis,  must  be  studied  to 
account  for  the  constipation. 

Chronic  peritonitis,  an  important  factor  in  constipation,  is  frequently  due 
to  chronic  peritoneal  inflammation.     In  the  major  regions  of  peritonitis  tne 

23 


354  THE  ABDOMINAL  AND  PELVIC  BRAIN 

story  of  constipation  is  told.  Chronic  peritonitis  occurs  in  the  oviducts  (80 
per  cent),  in  the  ileo-coeco-appendicular  region  (70  per  cent,  over  right 
psoas),  in  the  mesosigmoid  (80  per  cent,  over  left  psoas),  in  the  chole- 
cyst  and  right  colonic  flexure  region  (45  per  cent),  between  the  right  kidney 
and  the  liver  (40  per  cent),  i.  e.,  muscular  trauma  on  viscera  induces  ihe 
migration  of  germs  or  their  products  through  the  visceral  mucosa,  muscularis 
and  finally  into  the  adjacent  peritoneum  inciting  plastic  peritonitis. 

There  may  be  defective  innervation  of  the  muscularis  of  the  digestive 
tract  and  abdominal  wall  (splanchnoptosia).  Brain  and  spinal  cord  disease 
(insane  and  neurotic)  and  exhausted  disease. 

Inhibition  of  reflex  action  may  arise  to  check  defecation,  as  from  fissure, 
ulcer,  hemorrhoid,  operation,  painful  vesical  affections,  hypertrophy  of  anal 
sphincter.  Also  constipation  is  associated  with  lethargy  or  sluggishness  of 
the  bowels  from  local  peritoneal  or  visceral  inflammation,  as  appendicitis, 
ovaritis,  salpingitis,  cholecystitis,  pelvic  peritonitis.  It  is  in  such  cases  that 
opium  (a  sedative  to  the  local  irritation)  acts  as  a  cathartic. 

The  state  of  the  contents  of  the  bowels  is  significant  as  chronic  dyspepsia, 
irregular  eating  and  evacuation  and  insufficient  fluid  accompanying  the  food. 

Anatomic  peculiarities  may  lead  to  constipation,  as  elongated  cecum, 
sigmoid,  and  adherent  U-shaped  transverse  colon,  all  of  which  may  lie  in  the 
pelvis.  Much  of  constipation  is  a  perversion  of  the  sympathetic  nerves  con- 
trolling the  tractus  intestinalis. 

VIII.  Sex. — Woman  is  more  liable  to  constipation  than  man,  because 
in  her  the  tractus  genitalis  is  violently  changed  periodically — robbing  the 
tractus  intestinalis  of  its  usual  quantity  of  blood  (puberty,  menstruation,  preg- 
nancy, and  pelvic  disease) ;  (2)  woman  is  less  active,  more  sedentary  than 
man;  (3)  woman  is  afflicted  with  more  splanchnoptosia;  (4)  woman  experi- 
ences more  changes  in  her  visceral  circulation  (during  sexual  life)  than  man 
(physiology  and  pathology  of  genitals). 

IX.  Age  Relations. — In  senescence  constipation  may  occur  from  limited 
food  employed,  limited  exercise,  and  limited  functions,  due  to  the  degenera- 
tion of  senescence.  In  senility,  peristalsis,  absorption,  secretion  and  sensation 
is  limited  from  limited  blood  supply,  due  to  arterio-sclerosis.  In  pueritas  ana- 
tomic peculiarities  exist.  The  tractus  intestinalis  develop  irregularly,  the 
nervous  system  is  not  in  final  established  control,  the  mucosa,  muscularis, 
tractus  nervosus  and  tractus  vascularis  may  be  defective  in  development. 
Catarrh  occurs  with  facility  and  frequently.  The  tractus  intestinalis  is  sub- 
ject to  vast  vicissitudes  of  fortune,  both  in  regard  to  food  and  attacks  of 
catarrh.  Hence  its  circulatory  life — its  basic  life — is  subject  to  vast,  frequent 
and  rapid  changes. 

Constipation  is  a  neurosis  of  the  fecal  reservoir.  It  belongs  essentially 
among  the  affections  of  the  sympathetic  nerves. 

The  system  of  nerves  (including  Auerbach's  and  the  Billroth-Meissner 
plexuses)  which  rule  the  gastro-intestinal  tract  is  strictly  in  the  domain  of  the 
sympathetic.  However,  the  physiological  manifestations  of  the  nerves  ruling 
the  enteron  are  quite  different  from  those  ruling  the  colon.     The  nerves  ruling 


CONSTIPATION   BELONGS   TO    THE   COLON  355 

the  enteron  act  with  intense  vigor  and  great  rapidity.  The  nerves  ruling  the 
colon  and  rectum  act  with  moderate  force  and  very  slowly.  The  enteron 
rapidly  forces  the  contents  of  Bauhin's  valve  in  a  few  hours.  The  nerves  of 
the  colon  and  rectum  act  slowly,  evacuating  the  fecal  reservoir  usually  once 
every  twenty-four  hours. 

The  changes  in  the  physiological  action  from  the  vigorous,  rapid  motion 
of  the  enteron,  to  the  moderate,  slow  movement  of  the  colon  and  rectum, 
must  be  due  to  the  intervention  of  the  inferior  mesenteric  ganglion,  located 
at  the  root  of  the  inferior  mesenteric  artery,  which  emits  its  radiating 
branches  along  the  inferior  mesenteric  artery,  supplying  the  left  end  of  the 
transverse  colon,  the  left  colon,  the  sigmoid  flexure  and  rectum.  The  right 
colon  and  the  right  half  of  the  transverse  colon  are  supplied  by  the  abdominal 
brain,  sending  branches  along  the  superior  mesenteric  artery.  Now,  it  is 
quite  probable  that  the  slow  movement  of  the  nerves  belongs  entirely  to  the 
left  colon,  sigmoid  and  rectum,  which  is  entirely  supplied  by  branches  of  the 
inferior  mesenteric  ganglia. 

Hence,  for  the  regular  periodic  evacuation  of  feces,  a  habit  established 
by  ages,  we  must  look  to  the  immediate  rhythmic  control  of  the  inferior 
mesenteric  ganglion.  This  is  in  accord  with  the  idea  that  the  stool,  before 
expulsion,  lies  in  the  sigmoid  and  rectal  ampulla.  That  the  portion  of  the 
bowel  concerned  in  evacuation  is  under  control  of  a  nervous  mechanism,  may 
be  inferred  from  the  fact  that  a  person  can  establish  almost  any  definite  hour 
for  regular  defecation.  A  person  can  sometimes  restrain  the  stool  without 
difficulty  for  several  days.  For  the  cause  of  constipation  we  must  look  to  a 
peculiar  nervous  disturbance  in  the  peristalsis,  absorption,  secretion,  and  sen- 
sation of  the  colon,  or  of  that  part  of  the  colon  supplied  by  the  branches  of 
the  inferior  mesenteric  ganglion. 

In  constipation  the  feces  are  found  in  the  colon  and  not  in  the  enteron. 
This  abnormality  of  the  colonic  innervation  may  be  congenital,  or  acquired. 
Some  individuals  are  constipated  from  childhood.  A  boy  of  fifteen  came  to 
my  office  a  short  time  ago  who  had  never  had  a  stool  from  babyhood  onward 
without  a  rectal  injection,  or  some  strong  physic.  By  careful  examination  it 
appeared  that  neither  the  cerebro-spinal  nor  the  sympathetic  system  was  fully 
or  completely  developed.  However,  in  a  month,  from  physical  procedures, 
select  food,  ample  fluid  at  regular  intervals,  massage,  rectal  injections,  vigor- 
ous riding  and  regular  stool  hours,  we  secured  a  habit  of  daily  evacuation. 
Here,  doubtless,  the  trouble  was  congenital — deficient  and  imperfect  develop- 
ment. Depressing  mental  affections  derange  the  regular  bowel  action.  How- 
ever, in  constipation  accompanying  melancholia,  or  mental  disturbances,  it 
seems  to  me  that  it  is  impossible,  at  present,  to  decide  which  is  the  cause  and 
which  is  the  effect.  To  illustrate  the  influence  of  the  nervous  system  over 
bowel  evacuation,  observe  how  a  railroad  journey,  a  change  of  locality, 
festival  and  change  of  labor,  affect  a  constipated  condition.  Besides,  autop- 
sies of  persons  dead  from  other  diseases  teach  that  in  constipation  seldom 
can  structural  lesions  be  demonstrated.  The  chief  features  of  habitual  consti- 
pation tend  to  show  that  the  abnormal  condition  must  be  sought  in  a  neurosis 


356  THE  ABDOMINAL  AND  PELVIC  BRAIN 

of  the  colon  (especially  to  the  left  colon,  the  sigmoid  and  rectum).  The 
exact  nature  of  the  colonic  affection  is  unknown.  Another  factor  in  constipa- 
tion is  that  though  the  nervous  system  of  the  colon  be  fairly  developed,  yet 
the  muscularis  of  the  colon  is  not  normally  developed.  There  is  atony  of  the 
colonic  wall,  well  expressed  by  old  Latin  authors  as  atonia  intestini.  But  in 
this  case  perhaps  the  colon  muscular  atrophy  refers  to  the  nerves,  as  they 
control  the  lumen  of  the  blood-vessel,  which  is  the  real  nourisher  and  instiga- 
tor of  function. 

In  regard  to  the  relations  of  the  skeletal  muscles  to  the  intestinal  muscles, 
in  constipation,  we  maintain  that  they  are  entirely  independent  of  each  other, 
except  mechanically. 

The  subject  with  the  most  weakened  and  miserable  condition  of  the 
skeletal  muscles  may  be  absolutely  regular  in  bowel  evacuation,  or  may  suffer 
severe  constipation.  Of  course,  we  must  not  omit  the  mechanical  influence 
of  the  abdominal  muscles  in  defecation.  The  abdominal  muscles  increase 
the  intra-abdominal  pressure,  and  thus  aid  evacuation,  but  it  is  not  likely  that 
they  increase  peristalsis.  Perhaps  in  general  the  skeletal  or  intestinal  mus- 
cles play  but  a  small  role  in  constipation.  The  matter  lies  closer  to  the  nerv- 
ous system. 

Bouveret  and  Dunin  have  claimed  that  habitual  constipation  was  a 
frequent  accompaniment  of  general  nervousness,  especially  of  neurasthenia; 
that  the  neurosis  was  the  constipation,  not  the  constipation  the  cause  of  neu- 
rosis. This  idea  is  apt  to  prevail  with  most  force  among  those  physicians 
who,  in  curing  the  patient  of  the  general  neurosis,  neurasthenia,  have  seen 
the  constipation  disappear.  Fleiner  asserts  that  stool  retardation  is  due  to 
spasmodic  contraction  of  the  colon  segments,  grasping  their  contents.  This 
would  make  the  trouble  depend  on  the  nervous  system. 

The  mechanical  conditions  that  induce  constipation  will  not  be  here  con- 
sidered, except  so  far  as  their  purely  nervous  mechanism  and  influence  is 
concerned.  Hence,  such  factors  as  strangulation  by  peritonize  bands  and 
through  apertures,  and  the  mechanical  difficulties  of  splanchnoptosia  and 
pressure  of  abdominal  tumors,  are  not  here  discussed.  However,  we  must 
not  overlook  the  obstacles  placed  in  the  way  of  the  intestinal  nerves  by 
inflammation  of  any  one  of  the  bowel  coats,  or  tunics,  as  peritonitis,  or 
Inflammation  of  the  muscularis,  or  of  the  mucosa.  As  abdominal  surgeons, 
we  well  know  that  acute  peritonitis  produces  immediate  constipation,  check- 
ing peristalsis  by  edema,  congestion  and  exudation,  into  one  of  the  bowel 
tunics,  especially  the  peritoneum.  The  peripheral  bowel  nerve  apparatus  is 
deranged  by  pressure,  infection  and  malnutrition.  It  may  rapidly  recover. 
But,  doubtless,  a  crippled  and  defective  condition  frequently  remains — non- 
mechanical.  As  a  result  of  peritonitis  or  inflammation  of  any  one  of  the 
bowel  tunics,  producing  habitual  constipation,  we  must  especially  examine 
the  flexura  coli  lienalis  and  the  flexura  sigmoidea.  Not  infrequently  the 
action  of  the  distal  end  of  the  diaphragmatic  muscles  produces  inflammation 
of  the  left  colon,  by  inducing  migration  of  microbes  through  muscular  trauma. 

Also  the  conditions  disturbing  the  rectal  nerves  must  be  considered  as 


CONSTIPATION  DUE  TO  DIMINUTIVE  VISCERA  357 

causing  congestion  and  results.  In  constipation  we  only  include  the  colon 
segment  supplied  by  the  branches  of  the  inferior  mesenteric  ganglion.  It 
must  not  be  supposed  for  one  moment  that  peritonitis  around  the  evacuating 
fecal  depository  is  always  recognized.  Far  from  it,  for  in  some  six  hundred 
recorded  adult  autopsies  I  found  evidences  of  peritonitis  in  the  peritoneum  of 
the  left  colon  in  fully  eighty  per  cent  of  subjects.  In  fact,  in  the  mesosigmoid 
alone  there  was  about  seventy-five  per  cent  of  peritonitis. 


X-RAY  OF  DUCTUS  BILIS  ET  DUCTUS  PANCREATICUS 

Fig.  82.       This  illustration   suggests  the   quantity   of  nerves   required   to  ensheath  the 
ducts  and  vessels  of  the  liver  and  pancreas  as  fenestrated,  nodular  plexuses. 

Constipation  may  arise  in  some  persons  from  deficient  or  abnormally 
small  abdominal  brain,  or  from  premature  senility  in  the  abdominal 
sympathetic,  which  innervates  the  gastro-intestinal  tract;  also  from  cerebro- 
spinal disease,  which  inhibits  sources  of  energy.  Exhaustion,  mental  or 
physical,  is  a  potent  factor  in  constipation.     A  deficient  blood  supply  to  the 


358  THE  ABDOMINAL  AND  PELVIC  BRAIN 

parenchymal  ganglion  does  not  invigorate  it  sufficiently  to  induce  peristalsis. 
Exhaustion  from  over-exertion,  excessive  sexual  action,  or  extra  loss  of  blood, 
is  a  common  cause  of  constipation  in  young  women.  Depression  from  disap- 
pointment, from  death,  from  unrequited  love,  and  many  other  causes,  is  quite 
apparent  in  the  youthful,  producing  constipation — a  purely  nervous  phenom- 
enon. 

Constipation  in  lead  colic  is  a  nervous  phenomenon,  apparent  in  the 
intestinal  pain,  and  in  the  white  ring-like  contraction  of  the  circular  bowel 
fibers.  The  etiological  factor  is  the  irritation  of  the  parenchymal  ganglia  of 
the  bowel  wall  by  the  lead.  Spasm,  irregularity  of  inertia,  characterizes  the 
bowel  in  lead  colic,  except  in  the  etiology. 

Violent  and  persistent  constipation  depends  on  perverted  muscular  action, 
peristalsis,  absorption,  sensation  or  secretion,  due  in  general  to  some  defi- 
ciency of  nerve  force.  Colonic  inertia  may  rest  on  deficient  blood  supply  to 
the  parenchymal  ganglia,  but  this  is  directly  under  the  control  of  the  sympa- 
thetic, which  holds  sway  over  the  vessel's  caliber. 

It  must  always  be  borne  in  mind  that  the  size  of  the  sympathetic  differs 
very  much  in  different  individuals.  When  a  small-sized  visceral  nervous  sys- 
tem becomes  impaired,  as  it  easily  will,  its  phenomena  are  not  only  marked, 
but  difficult  to  correct.  A  large  dose  of  digitalis  slows  the  heart,  and  whether 
the  spinal  accessory  or  vagus,  digitalis  inhibits  its  action.  Nothnagel  sug- 
gests that  opium  works  similarly  on  the  splanchnics,  i.  e.,  by  slowing  peris- 
talsis. 

The  movements  of  the  enteron  are  largely  dependent  on  the  amount  of 
blood  in  the  intestinal  wall  i.  e.,  the  amount  of  fresh  blood  which  supplies 
the  parenchymal  ganglia. 

In  regard  to  antiperistalsis,  in  scores  of  experiments  on  dogs,  rabbits, 
guinea-pigs,  etc.,  I  saw  no  such  a  phenomenon.  The  vomiting  in  ileus  para- 
lyticus or  peritonitis  maybe  due  to  simple  contraction  of  the  stomach  on  the 
enclosed  contents,  when  the  fluids  pass  through  the  esophagus  in  the  direction 
of  the  least  resistance.  The  monstrously  large,  wide  cecum  of  herbivora,  a 
vestigial  stomach,  as  in  the  cow  and  horse,  is  emptied  by  peristalsis  and  not 
by  antiperistalsis,  as  noted  by  Jreper.  It  may  be  that  the  peristalsis  is 
increased  in  diarrhea,  yet  it  may  be  just  as  active  in  constipation,  but  in  this  the 
colonic  movements  are  vain  and  futile,  from  inability  to  force  the  contents 
into  successive  new  segments,  for  an  empty  bowel  is  a  still  one,  and  a  full 
bowel  is  an  active  one.  Also  active  peristalsis  will  invite  more  blood  into 
the  bowel  wall,  which,  in  turn,  induces  active  motion  in  the  segments. 
Doubtless,  herein  lies  the  value  of  abdominal  massage.  Whatever  checks  the 
flow  of  fresh  blood  to  the  bowel  wall  slows  peristalsis,  and  this  explains  the 
constipation  of  anemia. 

The  natural  secretions,  as  the  bile  and  the  pancreatic  fluids,  are,  perhaps, 
sufficient  alone  to  excite  the  parenchymal  ganglia  to  action,  with  but  little  or 
no  aid  from  the  splanchnics.  Hence,  from  the  inactive  hepatic  and  pancreatic 
secretion,  constipation  may  result.  Consequent  swelling  of  the  mucosa  from 
catarrh,  in  the  bile  ducts,  may  exclude  the  bile  from  other  channels,  which 
would  deprive  the  parenchymal  ganglia  of  their  accustomed  stimulus. 


CONSTIPATION  DUE  TO  PERVERTED  FUNCTION  359 

The  relations  of  adjacent  viscera  and  their  condition  may  influence  con- 
stipation. If  the  accustomed  secretions,  bile,  pancreatic  and  gastrointesti- 
nal, diminish,  the  bowel  will  not  receive  the  impulse  which  the  normal  amount 
of  secretions  impart,  and  peristalsis  partially  fails.  Diarrhea  may  be  insti- 
gated by  congestion,  then  by  edema  and,  instead  of  infiltrating  the  bowel 
wall,  the  result  may  be  rapid  exudation  and  diarrhea. 

Increased  peristalsis,  however,  is  not  necessarily  accompanied  by 
increased  secretion  and  exudation.  The  irritation  which  produces  the  peri- 
stalsis may  so  irritate  the  parietal  intestinal  ganglia  as  to  lessen  the  caliber  of 
the  blood  vessels  and  thus  check  secretion.  In  administering  certain  purga- 
tives it  is  found  that  they  are  followed  by  watery  evacuations.  But  this  may 
be  due  to  exalted  peristalsis  of  the  bowel,  allowing  insufficient  time  for 
absorption,  e.  g.,  in  times  of  quiet  peace  in  the  bowel  secretion  and  absorp- 
tion balance  each  other;  but  if  segments  of  the  bowel  become  irritated  by 
cathartics,  the  secretions  may  become  very  much  increased.  Yet,  owing  to 
the  vigorous  peristalsis,  the  fluids  are  rushed  distalward,  not  allowing  sufficient 
time  for  absorption. 

Constipation  is  generally  a  form  of  neurosis,  which  may  partake  of  a 
sensory,  motor  of  secretory  nature.  It  may,  however,  have  a  complex  course 
and  origin.  Constipation  is  a  condition  in  which  the  colon  is  not  evacuated 
daily,  except  by  the  aid  of  evacuants,  rectal  injections  or  physical  procedures. 
The  great  majority  of  the  human  family  having  a  daily  bowel  evacuation 
establishes  the  normal  frequency  at  once  a  day.  Exceptions  to  this  rule  may 
t>e  observed  in  certain  individuals  who  have  two  stools  daily,  others  one  stool 
in  two  or  three  days,  while  again  Pick  reports  patients  who  have  one  stool  a 
week.  A  doubtful  report  was  made  by  Dr.  Robert  Williams,  where  a  woman 
had  four  bowel  movements  a  year,  three  months  apart. 

This  irregularity  or  deviation  from  normal  defecation,  need  not  neces- 
sarily be  based  on  demonstrable  pathological  conditions.  In  constipation  we 
have  several  elements  to  consider,  the  mucosa,  the  muscularis,  the  blood-ves- 
sels, the  serosa,  and  the  nerve  supply. 

Perhaps  the  greatest  etiological  factor  of  constipation  is  enteritis,  catarrh 
of  the  colonic  mucosa.  This  would  involve  the  secretory  nerves.  In  fact, 
catarrhal  diseases  of  the  colonic  mucosa  are  the  active  factors  in  ever-chang- 
ing forms  of  constipation  and  diarrhea,  which,  doubtless,  involve  the  secretory 
nerves  more  than  the  motor  nerves.  Of  course,  the  regularity  of  stool 
depends  very  much  on  the  quality  and  quantity  of  food  ingested,  for  if  the 
food  leaves  no  residue  it  will  conduce  constipation,  for  the  greatest  of  all 
stimuli  to  colonic  motion  is  food  in  contact  with  the  intestinal  mucosa.  The 
peripheral  nerves  of  the  intestinal  mucosa  receive  impetus  and  sensation  from 
the  analward  moving  fecal  remnants. 

The  chief  influence  in  constipation  is  the  blood  and  food.  The  formation 
of  the  stool  depends  mainly  on  the  relation  of  the  solids  and  fluids  introduced 
into  the  stomach. 

A  close  relation  exists  in  constipation  between  the  quantity  of  food 
ingested,  and   the  resulting  fecal  residue,  which  actively  counts  in  treatment. 


360  THE  ABDOMIXAL  AXD  PELVIC  BRA IX 

Water  is  one  of  the  best  adjunct  evacuants.  An  exclusively  milk  diet  may 
create  constipation,  because  the  small  residue  is  insufficient  to  excite  peri- 
stalsis through  the  peripheral  nerves.  If  milk  creates  diarrhea,  it  is  likely 
from  some  sudden  development  of  germs,  or  fermentation.  The  utility  of 
graham  bread  in  curing  constipation  lies  in  the  fact  that  a  large  indigestible 
residue  remains,  inducing  colonic  contraction;  its  contained  salts  either  invite 
fluids  or  excite  peristalsis,  both  resulting  in  a  kind  of  massage,  or  acting  like 
a  foreign  body  to  the  mucosa. 

The  habits  of  life  are  closely  associated  with  constipation.  Society 
women  and  traveling  men,  with  irregular  ingestion  and  habits,  are  liable  to 
constipation.  Sedentary  habits,  deficient  exercise  and  excessive  mental  work, 
tend  to  produce  constipation.  The  use  of  narcotics,  deficient  drinking  of 
water,  active  perspiration  and  uncomfortable  closets  play  a  role  in  inducing 
constipation.  Excessive  eating  or  excessive  ingestions  in  the  gastrointesti- 
nal canal  may  lead  to  atony  of  the  intestinal  wall,  and  consequent  constipa- 
tion. The  causal  relation  of  constipation  must  be  sought  in  the  digestive 
tract  itself,  in  the  quality  and  quantity  of  food  ingested,  in  the  habits,  in  the 
relations  of  other  viscera. 

In  certain  cerebro-spinal  diseases,  the  sensory  nerves  of  the  intestinal 
mucosa  may  be  obtunded  or  blunted,  so  that  the  ordinary  peristalsis  is  not 
excited  by  the  ordinary  stimulus  of  food  residue.  The  peripheral  sensory 
apparatus  of  the  mucosa  does  not  perceive  the  usual  stimulus,  and  the  bowels 
become  torpid.  This  is  common  in  certains  form  of  hysteria,  or  better,  vis- 
ceral neurosis.  In  melancholies  and  hypochondriacs  the  barometer  of  their 
spirits  seems  often  to  tally  exactly  with  the  bowel  activity.  The  greater  the 
activity  of  their  bowels  the  more  lively  and  natural  their  mentality.  But  it 
must  not  be  forgotten  that  constipation  is  often  occasioned  by  the  mental 
condition.  We  know  personally  that  vomiting  may  be  induced  by  a  physical 
cause,  or  by  a  mental  one.  Some  will  vomit  from  seeing  a  fly  in  the  soup. 
So  it  is  with  a  genital  neurosis,  it  may  create  constipation,  or  may  induce  a 
local  neurosis  by  bathing  the  innumerable  ganglia  with  waste-laden  blood. 
If  secretion  be  deficient,  absorption  continues,  the  feces  harden,  form  an 
increasing  plug,  and  becomes  such  an  impediment  that  even  vigorous  peri- 
stalsis will  not  produce  the  analward  movement  required. 

Heredity  and  congenital  ailments  play  a  role  through  the  defects  in  the 
nerves  of  the  intestines.  We  deal  here  chiefly  with  the  purely  nervous  influ- 
ence, as  the  intestinals  of  the  cachectic  may  be  confined,  or  may  act  very 
irregularly.  Persons  with  defective  nervous  systems,  as  idiots  and  the  insane, 
suffer  from  constipation.  The  ill-defined  hysteric  person,  or  the  neurotic 
subject,  is  painfully  afflicted  with  constipation,  with  sluggish  bowels,  and 
some  of  these  very  subjects  are  continually  complaining  of  colicky  pains, 
which  are  to  be  interpreted  as  vain  attempts  of  peristalsis  to  force  the  bowel 
contents  analward. 

In  constipation  splanchnoptosia  plays  its  role  by  flexing  the  intestine, 
producing  conditions  which  require  more  vigorous  peristalsis  to  overcome;  in 
short  by  compromising  the  bowel  caliber.     In   splanchnoptosia  the  hepatic 


FECAL  RESERVOIR— PART  OF  TRANSVERSE  COLON        361 

and  splenic  flexures  are  both  made  more  acute  by  the  consequent  dragging  of 
the  ligamentutn  hepatico-colicum  et  phrenico-colicum  sinistrum. 

Relaxed,  pendulous  abdominal  walls  are  incapable  of  exerting  normal  or 
sufficient  pressure  on  the  tractus  intestinalis  to  control  circulation  (lymph  or 
blood)  or  to  expel  the  feces. 

The  fecal  reservoir,  as  previously  stated,  is  the  left  half  of  the  transverse 
colon,  the  left  colon,  the  sigmoid  and  rectum,  the  field  ruled  by  the  inferior 
mesenteric  ganglion.  It  has  been  asserted  by  my  respected  teacher,  Noth- 
nagel,  that  constipation  is  relatively  frequent  in  comparison  with  the  rarity 
of  peritoneal  fixation.  I  wish  respectfully  to  differ  from  this  excellent  and 
instructive  Viennese  teacher.  In  some  six  hundred  personal  autopsies  I  found 
peritonitis  in  the  fecal  reservoir  in  at  least  eighty  per  cent  of  the  subjects. 
This  peritonitis,  due  to  two  causes,  viz.,  traumatic  muscular  action  of  the 
psoas  magnus  on  the  sigmoid,  and  of  the  distal  left  limb  of  the  diaphragm  on 
the  left  colon,  which  induces  migration  of  pathologic  microbes  to  the  serosa; 
and  the  abrading  of  the  mucosa  of  the  fecal  reservoir  at  the  flexures  (splenic 
and  sigmoid),  allowing  the  wound  to  become  infected,  and  the  migration  of 
pathogenic  germs  to  the  serosa. 

Nowhere  in  the  body  is  infection  from  the  mucal  abrasion  more  definite 
than  at  the  ligamentutn  phrenico-colicum  sinistrum.  In  six  hundred  adult 
autopsies  we  found  that  the  fecal  reservoir  was  afflicted  with  peritonitis 
in  more  than  eighty  per  cent  of  the  cases.  Did  eighty  percent  of  these  cases 
suffer  from  constipation?  We  think  not.  Therefore,  according  to  our  six 
hundred  autopsies,  peritonitis  of  the  fecal  reservoir  is  far  more  common  than 
constipation,  for  eighty  per  cent  of  adults  do  not  suffer  from  constipation. 
Hence,  we  are  forced  to  the  opinion  that  peritonitis  of  the  fecal  reservoir  has 
undoubtedly  an  influence  in  inducing  constipation,  by  traumatizing  the  nerves 
presiding  over  defecation.  The  nerves  may  suffer  from  pressure  by  exudates 
or  edema,  from  congestion  or  malnutrition.  The  final  outcome  is  derange- 
ment of  the  nerves  of  the  fecal  reservoir — exaltation  or  debasement  of  sensa- 
tion and  motion.  As  probability  is  the  rule  of  life,  the  results  of  peritonitis 
cf  the  fecal  reservoir  is  here  referred  to,  and  not  acute  peritonitis.  I  have 
shown  (Peritoneal  Adhesions  After  Laparotomy,  Anter,  Gyn.  and  Obstet. 
Jour.,  December,  1*95)  that  gross  peritoneal  adhesions  (bands)  attached  to 
organs  cf  maximum  peristaltic  action,  as  the  middle  of  the  sigmoid  flexure 
and  the  oviducts  (or  their  amputated  ends),  the  mobile  bladder,  or  the  active 
peristaltic  loop  of  enteron,  frequently  create  very  much  pain,  though  not 
necessarily  constipation.  Yet  the  finer  pathological  infiltrations,  perhaps, 
not  even  microscopic,  or  at  least  insufficient  to  create  condition  of  the  fecal 
reservoir  which  may  be  far  more  effective  in  causing  constipation,  than  the 
gross  peritoneal  bands  which  simply  fix,  dislocate  viscera,  or  parts  of  viscera, 
are  an  important  factor  in  inducing  constipation  in  splanchnoptosia.  Perhaps 
splanchnoptosia  should  be  viewed  as  a  constitutional  disease,  a  general  neuro- 
sis. The  viscera  supports  very  gradually  elongate  in  splanchnoptosia,  and 
the  nerves  as  gradually  lose  their  tone.  That  the  visceral  nerves  ar<  involved 
in  splanchnotosia  is  very  evident    from    the  manifest    derangement    of    the 


3G2  THE  ABDOMINAL  AND  PELVIC  BRAIN 

nerves  of  sensation,  motion,  absorption,  and  secretion.  Splanchnoptosia  is 
a  weakening  of  the  nervous  system,  a  special  slackening,  or  elongation  of  the 
visceral  supports,  which  we  must  acknowledge  is  not  manifest  in  the  digest- 
ive tract  muscles,  but  attacks  the  skeletal  muscles  (e.  g.,  of  the  abdominal 
wall). 

Every  practitioner  has  observed  that  with  the  induction  of  habitual  con- 
stipation a  peculiar  nervous  phenomenon  also  arises.  The  popular  opinion 
is  that  the  constipation  is  the  cause  of  the  neurosis,  but  such  an  opinion  does 
not  always  stand  the  test  of  analysis.  Is  the  neurosis  not  the  cause  of  the 
constipation?  The  finer  beginning  of  the  neurosis  was  not  observed,  while 
the  grossness  of  constipation  is  discernible  from  beginning  to  end.  After 
constipation  has  once  started,  a  train  of  symptoms  may  set  in,  as  long  reten- 
tion of  the  feces  allows  them  to  become  dry  and  hard  from  absorption  of 
fluids.  The  feces  become  pressed  into  the  saccules  of  the  colon,  as  hard, 
irregular  masses,  known  as  scybala.  Such  masses,  by  continued  pressure, 
may  produce  mucus  ulceration.  The  subject  experiences  fullness  in  the 
abdomen  and  disagreeable  sensations;  the  appetite  disappears,  gases  are 
eructed,  and  a  disagreeable  taste  arises.  The  skin  may  assume  a  muddy 
color,  and  the  fecal  masses  may  be  covered  with  mucus  in  various  quantities. 
Some  practitioners  falsely  attribute  the  slime,  or  mucus,  to  colonic  catarrh. 
The  excessive  mucus  is  due  to  irritation  of  the  mucosa  by  the  fecal  masses, 
which  irritation  may  also  induce  a  hyperemia  of  the  mucosa,  producing  dis- 
ordered secretion,  with  fermentation  and  gases.  The  fecal  accumulation  can 
produce  not  only  a  transitory  mucal  hyperemia,  excessive  secretion  and 
diarrhea,  but  anatomic  changes,  such  as  colonic  catarrh,  trauma  of  the  colonic 
wall  and  local  peritonitis.  Considerable  colic  may  arise  from  the  attempts 
of  the  colon  to  expel  the  large  accumulated  masses,  which  palpation  may 
reveal. 

But,  to  speak  of  the  difficulties  arising  from  hardened  masses  of  accum- 
ulated feces  is  only  to  bring  in  mechanical  difficulties,  with  all  their  train  of 
evils,  on  the  three  tunics  of  the  colon  and  their  functions,  which  is  not  our 
chief  theme.  Our  contention  is  that  constipation  is  a  neurosis  of  the  fecal 
reservoir. 

To  illustrate  how  intimately  the  nervous  system  rules  the  fecal  reservoir 
in  its  periodic  evacuations,  all  that  is  necessary  is  to  recall  how  many  patients 
relate  that,  on  change  of  business,  residence,  or  scenery,  the  evacuations  being 
neglected,  cease  their  regularity.  So  far  as  I  am  aware,  constipation  always 
has  one  of  its  results,  the  collection  of  feces  in  the  colon,  from  the  rectal 
ampulla  to  Bauhin's  valve,  but  the  chief  locality  is  the  middle  of  the  trans- 
verse colon  to  the  rectal  ampulla.  The  collection  of  fecal  masses  in  the  right 
colon  is  rare,  and,  perhaps,  in  the  right  half  of  the  colon  it  is  also  rare,  except 
from  mechanical  causes,  i.  e,  if  half  of  the  colon  be  full  of  hardened  feces,  the 
right  half  will  be  full,  from  the  physical  fact  of  its  inability  to  force  them 
analward. 

The  train  of  evils  resulting  from  constipation  is  almost  endless,  e.  g..  the 
fecal  masses  produce  pressure  on  the  returning  veins  of  the  fecal  reservoir, 


CONSTIPATION  A  NEUROSIS  363 

causing  congestion,  especially  in  the  rectal  veins,  resulting  in  hemorrhoids. 
Perier  has  recently  attempted  to  show  that  the  so-called  "fecal  fever"  is  due 
to  absorption  from  the  digestive  tract.  The  proof  of  this  he  demonstrates  by 
a  cathartic  reducing  the  fever.  This  view  of  Perier  has  some  show  of  truth 
in  it,  for  in  puerperal  sepsis,  in  fever  after  operation,  a  cathartic  reduces  the 
fever  like  a  charm.  The  drain  by  the  cathartic  directs  the  poison  outward. 
However,  it  must  be  remembered  that  high  temperature  subsequent  to  some 
pelvic  operations,  is  rather  due  to  absorption  of  septic  matter  remaining  in 
the  pelvis  than  absorption  from  the  bowel.  For  long  past  and  even  to-day 
certain  widespread  opinions,  in  regard  to  certain  definite  connections  between 
the  central  nervous  system  and  constipation  exist.  Constipation  and  the  cen- 
tral nervous  system  are  brought  into  close  relations.  All  grades  of  symptoms, 
from  the  slightest  disturbance  to  hypochondrical  and  severe  psychical,  are 
included  as  due  to  constipation.  Certain  writers  have  tried  to  show  that 
relations  exist  between  dyspepsia  and  constipation  on  the  one  hand,  and 
hypochondria  and  melancholia  on  the  other.  Virchow  started  such  views 
nearly  fifty  years  ago,  and  Virchow  always  wrote  with  a  pencil  of  light.  The 
celebrated  neurologist,  Romberg,  claimed  in  1850,  that  constipation  could 
induce  hypochondria.  It  is  not  strange  that  the  opinion  of  such  giants  as 
Virchow  and  Romberg,  both  strengthened  by  observations,  should  prevail  so 
long.  But  our  belief  is  that  constipation  is  a  neurosis  of  the  fecal  reservoir. 
Hence,  constipation,  melancholia,  and  hypochondria  are  the  result  of  neuro- 
sis, and  not  the  cause.  We  must  look  to  neurasthenia  as  the  forerunner  of 
constipation,  as  the  neurotic  invader  of  the  fecal  reservoir  bringing  in  its  wake 
constipation.  When  neurasthenia  and  melancholia  enter,  the  process 
becomes  retarded.  Recently,  Dunin  has  favored  the  view  that  constipation 
is  the  result  of  a  neurosis  and  not  the  cause.  True  it  is  that  nervous  per- 
sons do  not  always  suffer  from  constipation  nor  are  non-nervous  persons 
invariably  free  from  it,  but,  first,  be  it  remembered  that  the  fecal  reservoir  is 
chiefly  under  the  influence  of  the  inferior  mesenteric  ganglion,  and  its  radiat- 
ing nerves  (sympathetic),  and  not  the  cerebro-spinal,  though  the  last-named 
exercises  certain  influences  over  the  fecal  reservoir;  also,  that  the  fecal  neu- 
rosis is  a  local  affair,  i.  e.,  the  peripheral  nerves  supplying  the  colon  in  area 
of  the  inferior  mesenteric  artery  may  be  attacked  by  disease,  independently 
of  the  remaining  sympathetic  and  cerebro-spinal  systems. 

The  general  view  here  entertained  in  regard  to  constipation  and  neurosis 
is:  That  the  constipation  is  the  cause  of  nervous  symptoms,  e.  g.,  a  person 
suffers  for  several  days  from  constipation  and  light  cerebral  symptoms  arise, 
as  headache,  dizziness,  pressure  in  the  head  and  inability  to  think  well. 
There  may  be  feelings  of  heat  in  the  head  and  considerable  general  languor. 
The  urine  may  be  a  little  scanty  and  high-colored,  with  hot  and  dry  skin. 
There  is  often  slight  respiratory  disturbance.  Physicians  generally  attempt 
to  prove  that  all  these  cerebral  symptoms  depend  on  the  several  days  of  con- 
stipation, from  the  fact  that  after  a  brisk  cathartic  the  cerebral  symptoms 
disappear.     This  circle  may  be,  and  often  is,  repeated  in  the  same  individual. 

At  first  sight    this  explanation,  with   its  practical   demonstration,  seems 


364  THE  ABDOMIXAL   AXD  PELVIC  BRAIN 

very  laudable.  But  is  it  satisfactory?  Can  not  the  neurosis,  the  subjective 
light  cerebral  symptoms,  be  the  cause  of  constipation?  It  is  not  easy  to 
give  a  categorical  proof  of  this.  The  disturbance,  or  hindrance,  in  respiration 
and  circulation  may  find  an  explanation  in  the  elevation  of  the  diaphragm. 

The  cerebral  circulation  may  be  disturbed  by  the  reflex  irritation  of  the 
abdominal  viscera,  transmitting  the  irritation  by  way  of  the  lateral  chain  of 
the  sympathetic  and  the  splanchnics.  Leube  has  recently  reported  cases  where 
the  person  became  dizzy  from  pressure  in  the  rectum,  either  by  fecal  masses, 
or  by  the  finger.  Here  the  dizziness  arises  from  irritation  of  the  hemorrhoidal 
plexus  of  nerves. 

Again,  Senator  suggests  that  the  absorption  of  certain  gases,  as  sulphu- 
reted  hydrogen,  might  induce  poisonous  symptoms.  Xothnagel  suggests  that 
in  constipation  ptomaines  might  be  absorbed,  inducing  cerebral  symptoms. 
But  Bouchard  demonstrated  that  toxic  fecal  ptomaines  may  occur  in  fluid 
feces,  as  is  seen  in  the  large  amount  found  in  the  urine  of  patients  afflicted 
with  diarrhea.  Again,  the  cerebral  symptoms  depend  on  the  constipation. 
Is  the  argument  the  same  with  melancholia  and  hypochondria?  Does  it 
depend  on  constipation?  In  other  words,  does  constipation  cause,  in  other- 
wise healthy  persons,  hypochondria,  or  other  psychoses?  We  think  it  does 
not.     The  proposition  should  be  made  in  two  forms: 

(a)  Constipation  may  occur  in  otherwise  healthy  persons.  These,  we 
claim,  do  not  suffer  the  hypochondria  and  psychoses. 

(b)  Constipation  occurs  in  patients  wTith  a  neurotic  tendency.  These 
last  are  the  subjects  which  suffer  from  melancholic  psychoses  during  constipa- 
tion. It  is  undeniable  that  psychical  depression  may  develop  during  consti- 
pation in  certain  persons,  but  the)-  are  of  the  neurotic  type,  and  in  these  the 
abdominal  disturbance  of  the  bowels  would  similarly  affect  (as  disturbances  in 
any  other  functions)  the  weakest  point,  i.  e.,  the  part  of  the  animal  economy 
which  resists  the  least.  Single-handed  and  alone  constipation  does  not  create 
hypochondria  and  melancholia,  but  in  a  system  burdened  with  neurotic  tend- 
encies, with  unstable  nerves,  they  may  exist,  but  are,  perhaps,  the  cause  of 
the  constipation. 

Virchow  says  the  following:  "Das  bci  cincr  gewissen  errcgungs  faJiigkeit 
widerstands  losigkeit  (predisposition),  des  nerven  apparatus  storhungen  mit 
dem  character  der  exaltation  an  den  sensitiven  und  don  der  depression  und  den 
motorichen  nerven  kerrufen."  Freely  translated  it  is,  "That  by  certain  tend- 
encies (non-resistance,  predisposition)  of  the  nervous  apparatus,  disturbances 
of  the  abdominal  viscera  may  produce  the  character  of  exaltation  in  the  sen- 
sitive nerves,  and  depression  in  the  motor  nerves." 

It  appears  to  me,  however,  that  the  popular  professional  jdea  of  the  effect 
of  constipation  on  the  brain  is  exaggerated,  and  much  of  the  belief  is 
untenable. 

The  celebrated  English  author  and  physician,  Dr.  Barnes,  held  that  con- 
stipation was  the  cause  of  chlorosis.  Perhaps  this  view  arises  from  the  supposed 
fact  that  some  of  the  chlorotic  girls  recovered  after  cathartic  treatment. 
But,  since  chlorosis  is  a  disease  of  a  certain  age,  i.  e.,  from  fifteen  to  twenty- 


RELATIOX  OF  TRACTUS  INTESTINALIS 


365 


five  years,  such  a  fact  remains  to  be  proved,  for  the  constipation  accompany- 
ing chlorosis  constitutes  but  a  small  portion  of  the  ailments  atacked  by  it. 
Constipation  and  neurosis  are,  nevertheless,  close  relatives  in  many  subjects 
with  peculiar  nervous  symptoms. 

The  relation  of  the  gastrointestinal  canal  to  other  viscera  is  of  prime 
importance  as  modifying  peristalsis.  The  emphysematous  lungs  force  the 
diaphragm  distalward,  and  this  destroys  the  tendency  to  free  peristalsis. 
Heart,  liver  and  kidney  diseases,  if  they  produce  congestion  in  the  bowel 
coats — serosa,  muscularis  and  mucosa — will  lessen  peristalsis  and  consequent 


X-RAY  OF  DUCTUS  PANCREATICUS  ET  DUCTUS  BILIS 

Fig.  83.     The  pancreatic  and  liver  ducts,  ensheathed  by  a  network  of  fenestrated,  nodu- 
lar nerve  plexuses.     Also  the  portal  vein. 


fecal  motion.  Diabetes  induces  constipation  by  diverting  fluids  from  the 
intestinal  tract,  and  the  consequent  drying  of  the  feces.  In  the  chlorotic  and 
anemic  it  is  difficult  to  distinguish  cause  and  effect.  The}'  are  both  consti- 
pated. But  the  retardation  of  fecal  movements  may  be  followed  by  anemia 
and  chlorosis,  or  auto-intoxication.  However,  chlorosis  belongs  to  females, 
in  general,  from  puberty  to  the  age  of  twenty-five.  It  is  a  developmental 
disease.  In  fevers  deficient  peristalsis  induces  constipation.  Excessive 
sweating,  also,  renders  the  feces  dry,  and  the  diminution  in  the  amount  of 
food  taken  leaves  less  residue  to  stimulate  peristalsis. 

Fleischer  suggest  that  in  fevers  the  high  temperature  of  the  blood  bath- 


3G6  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

ing  the  ganglia  in  the  walls  of  the  bowel  tends  to  inhibit  peristalsis,    and 
hence  cause  constipation. 

Under  sympathetic  nerve  influence  we  are  not  including  constipation 
trom  mechanical  factors,  as  volvulus,  flexions,  obstruction  by  peritoneal 
bands  and  through  apertures,  pressure  from  tumors,  strictures,  or  dislocated 
organs.  Experience  teaches  emphatically  that  enteritis,  or  catarrh  of 
the  enteron,  induces  constipation.  If  catarrh  of  the  colon  and  enteron  exists, 
diarrhea  and  constipation  will  generally  alternate.  The  secretory,  as  well 
as  the  motor  nerves,  are  highly  involved  in  catarrh.  Ulcerative  processes  in 
the  mucosa  inducing  diarrhea  are  not  included  in  nerve  influence.  We,  of 
course,  have  constipation  in  atony  of  the  bowel  wall,  as  well  as  in  partial 
paresis. 

Bowel  weakness  arises  in  potators,  tabetic  and  tubercular  patients,  and 
in  those  with  progressive  splanchnoptosia. 

It  is  plain  to  any  one  that  a  neurosis  acts  in  various  ways  on  the  tractus 
intestinalis,  influencing  constipation  or  diarrhea.  The  hysteric  and  neuras- 
thenic both  suffer  from  irregular  constipation.  It  is  a  common  observation 
that  patients  who  complain  of  abdominal  neuralgias  suffer  more  or  less  from 
constipation.  It  appears  as  if  the  nerves  of  the  bowel  do  not  work  in 
harmony,  the  bowel  is  incapable  of  regularly  emptying  itself.  Besides,  neural- 
gia is,  doubtless,  a  malassimilation  of  a  sensory  nerve,  and  since  the  sensory 
and  motor  nerves  are  complements  of  each  other,  they  must  work  in  harmony 
to  accomplish  an  object — evacuation.  The  bowel  contents  irritate  the  peri- 
phery of  a  sensory  nerve  in  the  mucosa,  this  is  carried  by  the  organizing 
ganglia  of  the  muscular  wall,  which  induces  muscular  motion.  The  blood 
vessels  of  the  bowel  wall  exert  vast  influence  over  peristalsis,  and  the  vessels 
are  ruled  by  the  sympathetic  nerves. 

With  deranged  nerves  of  the  intestines  there  will  necessarily  be  deranged 
circulation,  and  either  congestion  or  anemia  induces  a  lowering  of  peristalsis 
— constipation.  The  circulation  on  the  surface  of  the  body  is  only  an  index 
of  what  is  occurring  inside.  Now,  it  is  common  in  neurotic  persons  to  observe 
a  dozen  marked  changes  in  the  superficial  circulation  in  a  single  day.  The 
changes  of  circulation  affect  the  bowel  wall  in  a  similar  way  that  they  do  the 
surface.  The  effectiveness  of  circulatory  changes  is,  perhaps,  best  observed 
in  the  serous  covering  the  bowel,  as  in  peritonitis,  where  constipation  exists. 
In  peritonitis  the  bowel  wall  becomes  edematous,  congested,  and  the  periph- 
eral nerve  apparatus  is  compromised  by  pressure  and  malnutrition,  so  that 
we  always  expect  constipation  in  peritonitis.     The  circulation  is  deranged. 

In  the  territory  of  the  secretory  nerves,  which  belong  to  the  sympathetic, 
as  well  as  the  motor  and  sensory  nerves  of  the  intestines,  a  vast  field  lies 
unopened.  At  ordinary  times  secretions  progress  in  definite  proportions,  but, 
pathologically,  we  have  excessive,  deficient,  or  disproportionate  secretions, 
e.  g.,  there  maybe  excessive  bile,  HC1,  gastric  or  pancreatic  fluids,  or  all  of 
these  may  be  deficient.  Again,  the  bile  may  be  secreted  in  proper  amounts, 
so  that  we  would  have  disproportionate  secretion,  which  induces  fermentation, 
the  development  of  gases,  tympany,  and  the  undue  development  of  certain 


local  and  general  symptoms  or  constipation 

microbes.  If  deficient  HC1,  or  bile,  be  secreted,  both  of  which  arc  antisep- 
tic, microbes  develop.  Also,  it  must  not  be  forgotten  that  deficiency  of  secre- 
tion checks  peristalsis,  whether  it  be  deficiency  of  bile,  pancreatic,  or  other 
gastrointestinal  fluids,  and  slowing  of  peristalsis  invites  constipation. 

To  illustrate  the  influence  of  nerves  over  peristalsis,  observe  how  the 
irritation  of  a  small  fissure  will  induce  constipation,  first  by  abstention  from 
stool  and,  second,  by  breaking  the  regular  habit  of  stool.  By  forcible  dilata- 
tion of  the  rectum  the  regular  stool  habit  assumes  its  old  course.  In  the  case 
of  anal  fissure  the  irritation  is  purely  reflex  on  the  remaining  portion  of  the 
gastre-intestinal  canal.  It  would  appear  that  constipation,  in  certain  forms, 
may  be  well  remedied  by  daily  dilatation  cf  the  sphincter.  This  dilate^  and 
flushes  its  peripheral  capillaries.  Dr.  Bier  reports  successes  in  the  Wiener 
Med.  Blaetter,  1891,  No.  25. 

The  complex  symptoms  of  constipation  may  be  indecisively  divided  into 
general  and  local  symptoms.  The  general  and  most  disastrous  symptom  is 
that  of  auto-intoxication.  It  represents  a  series  of  manifestations  in  the 
territory  of  the  nervous  system,  whether  it  be  chronic  or  acute,  common 
symptoms  or  headache,  dizziness  and  neuralgias  about  the  abdomen,  as  well 
as  sleepiness,  melancholia,  languor,  a  feeling  of  debility  and  nausea.  Pick 
says  the  visible  expression  of  the  constipation  is  the  richness  of  excretory 
principals  in  the  urine,  and  the  increased  toxicity  of  the  same. 

One  of  the  local  symptoms  of  constipation  is  the  feeling  of  fullness  and 
pressure  in  the  abdomen,  which  is  generally  distended.  The  passage  of  gas 
gives  temporary  relief.  The  diaphragm  is  forced  proximalward,  compromis- 
ing the  heart,  so  that  it  not  infrequently  palpitates,  and  the  lung  manifests 
difficulty  in  respiration.  In  certain  cases  considerable  colic  is  produced  at 
stool,  from  irritation  of  the  bowel  wall  by  hard  fecal  masses.  The  positions 
of  local  colic  from  expelling  hardened  feces  are  the  ampulla  of  the  rectum, 
the  cecum,  the  hepatic  and  splenic  flexures,  the  middle  of  the  transverse 
colon,  and  S-romanum.  Large,  hard,  rough  fecal  masses  not  only  cause  much 
pain,  but  they  abrade  the  mucosa  and  finally  produce  ulcerations,  which  heal 
slowly. 

Visceral  Circulation  in  Constipation. — The  proverbial  advice  of  the  elderly 
doctor,  when  he  wishes  to  be  social,  entertaining  and  instructive,  is  to  keep 
the  head  cool,  the  feet  warm,  and  the  bowels  open. 

This  philosophic  advice  is  frequently  theoretical,  rather  than  practical, 
from  an  application  to  the  actual  living  habits  of  the  subject.  In  the  present 
modes  of  living  among  women  constipation  plays  an  extensive  and  damaging 
role.  The  evil  effects  of  constipation  extend  to  adjacent  visceral  tracts,  as 
circulation,  respiration,  and  particularly  on  the  tractus  glandularis — secretions. 
The  most  important  visceral  tract  of  life  itself  is  the  tractus  vascularis,  over 
which  the  sympathetic  nerve,  nervus  vasomotorius,  maintains  direct  control. 
An  ample  stream  of  fresh  blood  can  not  properly  irrigate  constipated  visceral 
organs.  In  constipation  one  or  more  of  the  four  great  common  visceral  func- 
tions— peristalsis,  secretion,  sensation  or  absorption — are  disordered.  The 
disturbance    of    circulation  in  constipation  may  be   local   or  general.     We 


368  THE  ABDOMINAL  AND  PEWIC  BRAIN 

observe  the  profound  anemia  of  girls,  frequently  following  the  phase  of 
puberty.  The  circulatory  changes  are  at  first  local,  later  general.  The 
anemic,  chlorotic  girl  (from  fifteen  to  twenty-five  years  of  age)  is  plump,  fat. 
and  beautiful — in  fact,  it  is  the  anemia  of  the  good-looking  girls.  It  appears 
concomitant  with  the  disordered  local  circulation  (genital);  the  later,  general, 
disordered  circulation,  is  accompanied  by  disordered,  hypertrophied  glandular 
system  (tractus  lymphaticus)  and  constipation.  The  chlorotic  girl  might 
profitably  pose  as  an  alabaster  or  marble  statue.  Hence,  disordered  circula- 
tion (pubertas),  accompanied  by  disordered  general  circulation,  disordered 
tractus  lymphaticus,  and  constipation  (disordered  peristalsis,  or  secretion,  or 
absorption). 

In  the  establishment  of  menstruation  numerous  local  (genital  congestion 
or  anemia)  or  general  (chlorosis)  circulatory  disturbances  arise.  In  pubertas 
the  luxuriant  vessels  (veins)  of  the  ovary  and  its  compensatory  balanced  arm, 
the  endometrium,  become  congested,  engorged,  which  robs  the  blood  from  the 
tractus  intestinalis  and  disturbs  not  only  local,  but  general  circulation,  which 
condition  is  intensified  in  gestation. 

Until  the  habit  of  menstruation  is  established  the  local  change  of  circula- 
tion may  induce  constipation.  In  fact,  I  have  relieved  numerous  gynecologi- 
cal patients  by  restoring  normal  evacuations  of  the  bowels,  and  vice  versa, 
normal  genitals  may  restore  normal  bowel  evacuation. 

In  short,  detailed  attention  to  the  circulation — a  matter  directly  under 
command  of  the  sympathetic — is  one  of  the  most  important  factors  in  regu- 
lating constipation. 

It  is  the  detailed  study  of  sanitorium  patients,  as  to  life,  habits,  diet  and 
fluids,  that  makes  the  sanitorium  financially  profitable  and  suggestive,  at  least 
to  the  so-called  surgeon  who  is  so  busy  with  major  operations  that  he  walks 
over  gold  and  silver  daily.  The  neglect  of  accurate  diagnosis  and  consequent 
neglect  of  detailed  treatment  and  defects  of  common  functions,  constipation, 
by  the  physician,  is  the  reason  of  the  multiplication  of  sanitoria,  and  the  con- 
sequent loss  of  feces  and  confidence  in  the  home  physician. 

It  is  the  duty  of  the  physician  in  defects  of  the  common  visceral  functions 
— peristalsis,  absorption,  and  secretion — to  introduce  visceral  drainage  to 
relieve  the  patient  of  waste-laden  blood,  and  restore  normal  circulation. 
The  physician  should  decide  in  detail  the  quality  and  quantity  of  the  food 
and  fluids  ingested,  and  determine  the  methods  of  sewerage.  He  should  rec- 
ognize the  secretory  and  motor  activity  of  the  tractus  intestinalis,  and  the 
fascio-elastic  muscular  apparatus  of  the  abdominal  wall,  which  aids  in  evacu- 
ating the  bowels. 

Women,  especially  the  young,  must  be  taught  the  absolute  necessity  of 
regular  daily  evacuations,  regardless  of  environments,  time,  place,  views,  or 
agreeability.  The  woman  should  know  that  exercise,  muscular  activity,  is 
necessary  for  the  abdominal  muscles  to  force  continually  the  bowel  move- 
ments, contents,  analward.  Active  bodily  movements,  fresh  air,  bicycling, 
walking,  aid  very  much  to  maintain  visceral  circulation. 

Artificial  checks  to  respiration,  as  the  corset  or  tight  bands,  check  circu- 


DIAGNOSIS  OF  CONSTIPATION  369 

lation,  especially  visceral,  and  hence  peristalsis,  absorption  and  secretions  of 
the  tractus  intestinalis  is  checked.  The  corset  is  an  enemy  to  circulation, 
and  a  friend  to  constipation  and  is  unhesitatingly  condemned. 

Only  ocular  demonstration  will  convince  a  woman  against  corsets,  so  firm 
has  become  the  senseless  iron  rule  of  fashion. 

To  illustrate  the  important  influence  of  circulation  in  constipation,  the 
first  week  of  marriage  may  be  noted.  The  extra  irritation  of  the  genitals 
induces  a  genital  hyperemia,  a  congestion  which  robs  the  blood  from  the 
tractus  intestinalis,  leaving  in  its  wake  intestinal  paresis — constipation. 

Menstrual  disturbances,  chronic  genital  inflammation,  entice  blood  from 
the  tractus  intestinalis,  leaving  defective  intestinal  peristalsis  from  lack  of 
blood.  Removal  of  chronic  congested  genitals  may  restore  normal  action  of 
the  genital  tract  by  returning  to  them  their  normal  blood  stream.  Not  only 
does  pregnancy  induce  constipation  by  enticing  a  continual  blood  stream 
toward  the  genitals  from  the  intestinal  tract,  but  in  the  puerperium  the 
abdominal  muscular  apparatus  has  lost  its  original  elastic  tone,  its  power  of 
compression.  The  enforced  corporeal  rest  and  non-irritating  food  adminis- 
tered engenders  a  constipation  by  disordered,  unbalanced  circulation. 

In  the  puerperium,  instead  of  an  abdominal  binder,  the  abdominal  mus- 
cles should  be  massaged.  The  patient  should  practice  on  the  abdominal 
muscles  gymnastic  exercises,  in  order  to  quickly  restore  them  to  normal 
action,  and  thus  avoid  one  of  the  prime  factors  of  splanchnoptosia. 

The  abdominal  binder,  the  enforced  rest,  and  concentrated  food  in  the 
puerperium,  all  tend  to  lessen  the  visceral  circulation,  especially  in  the  intes- 
tinal tract,  and  hence  to  entice  constipation. 

The  Diagnosis  of  Constipation. — First  and  foremost  an  examination, 
extending  from  mouth  to  anus,  is  a  prerequisite  to  diagnose  constipation. 

The  mouth,  and  especially  the  teeth,  unfold  an  important  story. 

The  state  of  the  abdominal  and  thoracic  walls  are  significant.  Does 
splanchnoptosia  exist  with  its  general  consequences? 

What  is  the  state  of  the  rectum  (fissure,  hemorrhoid,  ulcer?)  is  of  extreme 
importance. 

The  tractus  vascularis  tells  its  own  story  in  arterio-sclerosis,  which  would 
indicate  defective  circulation  in  the  splanchnic  area. 

Careful  palpation  of  the  plexuses  and  connection  cords  of  the  abdominal 
sympathetic  should  be  practiced,  as  they  regulate  the  caliber  of  the  splanch- 
nic vessels.  Tenderness  of  the  abdominal  sympathetic  plexus  indicates  an 
irritable  condition  of  the  viscera.  If  marked  sclerosis  exists,  the  abdominal 
aorta  is  palpable  and  tender.  It  is  enlarged,  movable,  and  pulsates  vigor- 
ously, The  tendernesss  is  to  be  localized  especially  along  the  plexus  aorticus 
distal  to  the  umbilicus,  and  in  the  plexus  celiacus  (abdominal  brain)  proximal 
to  the  umbilicus.  This  tenderness  indicates  a  neuritis  of  the  sympathetic,  or 
vasomotor  plexuses.  Colic,  due  to  spasm  of  vessels  (arterio-sclerosis),  must 
be  differentiated  from  colic  due  to  enteritis.  In  neuritis  of  the  sympathetic 
plexuses,  the  pain  and  tenderness  is  localized  in  the  celiac  and  aortic  plexuses, 
and  along  the  route  of  the  ensheathed,  which  is  characterized  by  spasmodic 

24 


370  THE  ABDOMINAL  AXD  PELVIC  BRAIX 

and  periodic  exacerbation.  Peritonitis  announces  a  more  diffuse  tenderness, 
and  it  is  less  spasmodic  and  periodic.  Enteritis  presents  tenderness,  localized 
in  the  course  of  the  enteron,  and  is  accompanied  by  other  symptoms,  as  mucus 
in  stools.  The  diagnosis  of  constipation  is  a  small  factor  in  practice,  but  the 
finest  head,  with  the  best  skill,  is  required  to  diagnose  the  etiology,  for  on 
the  cause  of  this  malady  rests  the  successful  treatment.  It  is  needless  to  say 
that  a  thorough  and  complete  physical  examination  is  absolutely  necessary. 
For  constipation  may  depend  on  the  kind  of  food  taken,  on  habits  of  life,  on 
drugs  employed,  or  on  defects  in  the  system.  Some  affirm  that  heredity  plays 
a  role  in  constipation;  however,  this  is  only  a  cloak  to  cover  what  we  do  no't 
know.  Many  persons  who  have  only  one  stool  in  two  days,  and  remain 
healthy,  are  not  constipated,  and  require  no  treatment. 

Treatment  of  Constipation — General  Remarks. — First  and  foremost  in  the 
treatment  of  constipation,  should  be  considered  the  diet.  Some  physicians 
have  a  diet  list.  In  certain  cases  it  is  convenient,  but  generally  of  little  value. 
Oatmeal  and  graham  bread,  with  milk  as  a  beverage,  leaves  ample  residue  to 
induce  peristalsis,  which  soon  overcomes  constipation.  In  such  cases,  also, 
a  few  daily  colonic  flushings  aid  wonderfully,  with  the  establishment  of  a 
regular  hour  for  evacuation.  Especial  stress  should  be  laid  on  the  matter  of 
avoiding  cathartics;  they  are  among  the  chief  causes  of  constipation.  The 
best  methods  of  curing  constipation  are  those  which  imitate  nature  the 
closest,  and  most  perfectly.     They  are,  in  order: 

1.  The  regulation  of  diet  (ingesta). 

2.  Physical  procedures. 

3.  The  judicious  use  of  laxatives. 

In  the  regulation  of  the  diet  several  factors  are  requisite,  viz.,  food  which 
leaves  a  large  residue,  which  will  impart  the  necessary  constant  stimulus  to 
successive  bowel  segments.  Peristalsis  requires  a  physical  stimulus,  a  bolus 
that  will  feel  its  way  from  stomach  to  anus.  The  diet  should  be  a  mixed  one 
of  cereals,  meats  and  fruits,  as  well  as  concentrated  foods.  It  should  be 
eaten  at  regular,  fixed  hours.  The  bowel  is  an  organ  wonderfully  inclined,  in 
certain  persons,  to  assume  sluggish,  stubborn  habits.  Subjects  who  eat  irreg- 
ularly are  apt  to  become  just  as  irregular  in  evacuation.  To  show  the  effect 
of  the  habit,  observe  how  much  more  women  are  constipated  than  men — a 
result  of  insufficient  physical  exercise,  or  sedentary  life.  Also,  ample  fluid 
should  be  taken  with  the  foods. 

The  good  effect  of  graham  bread  is  chiefly  due  to  the  large  residue,  and 
the  contained  salts — both  acting  physically  on  the  bowel,  causing  peristalsis. 
The  habits  of  the  use  of  narcotics,  drinking,  smoking,  chewing,  and  taking  of 
morphine,  sexual  abuses,  over-mental  activity,  etc.,  should  be  modified. 

The  second  method  of  treatment  in  constipation  is  the  use  of  some  physi- 
cal procedure.  Of  these  several  are  important.  Among  the  first  is  the  estab- 
lishment of  regular  habits  of  evacuation  and  overcoming  irregular  ones. 
The  bowels  should  be  evacuated  every  morning  after  breakfast,  i.  e.,  after 
drinking  hot  fluid  and  eating  hot  food. 

Heat  starts  peristalsis.     The  mental  state  has  much  influence  over  the 


TREATMENT  OF  CONSTIPATION  371 

bowels,  so  that  if  the  mind  is  set  on  a  distinct  hour  for  an  evacuation,  it  is 
prett)'  sure  to  be  secured.  Another  valuable  factor  is  regular  and  vigorous 
daily  exercise.  The  most  natural  are  walking,  horseback  or  bicycle  riding. 
The  habit  of  exercise  is  nearly  always  sufficient  to  overcome  constipation. 
Gymnastics  serve  a  similar  object. 

When  the  above  exercises  are  not  performed,  one  of  the  sovereign  cures 
of  constipation  is  voluntary  cultivation  of  the  abdominal  muscles,  or  massage; 
at  first,  weak  or  light  rubbing  should  be  employed  once  or  twice  daily;  subse- 
quently, vigorous  massage  should  be  carried  on.  Stroking,  rubbing,  tapping, 
kneading  and  gripping  the  abdominal  wall  should  be  judiciously  performed. 
The  large  intestine  should  be  massaged  from  cecum  to  rectum,  following  the 
line  of  the  colon,  and  the  direction  of  the  fecal  current.  Rolling  a  bag  of 
shot  or  dry  sand  over  the  abdomen  is  effective,  if  continued  many  days.  Much 
patience  on  the  part  of  both  physician  and  patient  will  be  required  to  continue 
the  massage,  for  it  may  need  a  month  to  accomplish  permanent  results  by 
this  process.  Rolling  on  the  abdomen  for  ten  or  fifteen  minutes  every  morn- 
ing accomplishes  goods  results  in  constipation.  Another  excellent  remedy 
for  both  its  mental  and  physical  effects,  is  electricity.  Either  the  galvanic  or 
the  faradic  current  is  effective.  The  muscle  walls  of  the  abdomen  can  not 
only  be  treated  by  electricity,  but  one  of  the  electrodes  may  be  inserted  into 
the  rectum.  Another  physical  procedure  of  great  value  for  a  limited  employ- 
ment in  constipation  is  irrigation,  or  colonic  flushings,  or  rectal  injections. 
However,  rectal  injections  blunt  the  sensibility  of  the  rectal  mucosa.  For 
mild  cases  a  rectal  injection  of  one-half  pint  of  plain  or  salt  water  is  sufficient 
to  irritate  the  bowel,  and  excite  an  evacuation.  In  more  stubborn  cases  a 
quart  of  water,  containing  irritants,  may  be  injected,  by  a  fountain  syringe, 
held  two  feet  above  the  patient,  and  allowing  the  fluid  to  flow  into  the  bowel. 
Another  method  is  turn  a  chair  upside  down,  place  a  quilt  over  it,  and  then 
place  the  patient  over  this  inclined  plane,  with  the  #hips  well  elevated,  and 
shoulders  well  down.  Then  allow  a  quart  of  water  (containing  desired  ingre- 
dients) to  gradually  pass  into  the  colon. 

Besides  the  water  injections,  one  may  employ  stimulants,  such  as  epsom 
salts,  olive  oil,  glycerine  and  water,  at  different  temperatures.  An  excellent 
rectal  injection  is  a  half  pint  each  of  molasses  and  milk.  It  is  hygroscopic. 
The  irrigation  is  accomplished  with  more  safety  and  efficiency  with  the  foun- 
tain syringe  at  a  low  level,  e.  g.,  about  two  feet  above  the  patient's  hips. 
Cold  fluid  injections  excite  the  bowels;  however,  warm  fluids  dissolve  feces 
more  rapidly. 

Olive  oil  treatment. — Constipation  is  benefitted  by  persistent  course  of 
administration  of  olive  oil  for  a  period  of  months.  I  ordered  a  tablespoonful 
after  each  meal.  The  chemical  action  of  the  olive  oil  is  a  result  of  the  sepa- 
ration of  the  oil  by  bile  and  pancreatic  ferments.  Through  the  bile  and  pan- 
creatic fluids  the  fatty  acids  and  soaps  are  produced  which  exert  a  mild  chem- 
ical action,  inducing  evacuation.  To  soften  and  dissolve  fecal  masses  olive 
oil  is  excellent.  The  value  of  the  olive  oil  employed  per  rectum  is  dependent 
not  only  on  its  physical  properties  as  softening  and  dissolving  feces,  coating 


372  THE  ABDOMINAL  AND  PELVIC  BRAIN 

and  protecting  the  mucosa,  and  diminishing  the  absorption  of  water,  but  also 
on  its  chemical  action. 

To  produce  an  immediate  stool,  a  cold-water  rectal  injection  of  one-half 
a  pint  will  be  the  most  effective,  as  it  at  once  induces  active  peristalsis.  This 
may  be  added  by  rolling  a  bag  of  sand  or  shot  over  the  abdomen.  Daily 
dilatation  of  the  rectum,  especially  when  it  is  inclined  to  spasm,  or  is  subject 
to  fissure,  ulceration  or  hemorrhoids,  is  a  usual  procedure.  However,  fissures, 
ulcers  and  hemorrhoids  are  proper  cases  for  operations. 

Finally,  in  the  treatment  of  constipation,  we  come  to  use  of  drugs — at 
once  the  most  disastrous  and  inefficient  of  all  methods.  Cathartics  are  to  be 
avoided  as  much  as  possible  in  constipation.  Constipation  is  generally  the 
result  of  catarrh.  Cathartics  influence  catarrh  injuriously  by  further  compli- 
cating the  circulation,  and  inducing  congestions  and  depletions.  In  the  treat- 
ment of  diseases  peculiar  to  women,  which  I  have  diligently  followed  for 
twenty  years,  and  where  constipation  is  a  common  matter,  I  seldom  advise  a 
cathartic,  pure  and  simple.  The  method  I  have  followed  successfully  for 
years  is  what  I  term  visceral  drainage,  presently  to  be  described.  Drastic 
cathartics  are  the  friends  of  constipation.  The  number  of  cathartics  is  very 
great.  The  choice  of  one  will  depend  on  whether  the  drug  is  intended  for 
long  or  short  use.  If  a  cathartic  be  employed  for  a  short  use,  to  secure  an 
immediate  evacuation,  one  of  vigorous  nature  should  be  selected.  For  this 
purpose  none  are  superior  to  mild  chloride,  followed  by  magnesium  sulphate. 
The  mild  chloride  stimulates  the  whole  gastro-intestinal  glandular  apparatus, 
while  the  magnesium  sulphate  induces  a  large  flow  of  fluids  into  the  bowel. 
I  have  used  these  cathartics  thousands  of  times,  and  have  not  yet  observed 
superior  ones.  The  violent,  drastic  cathartics,  such  as  croton  oil,  podophylin, 
colocynth  and  elaterium,  are  seldom  required. 

Should  a  cathartic  be  required  for  prolonged  use,  one  of  a  mild  nature 
should  be  selected,  such  as  rhubarb,  magnesium  sulphate,  senna,  aloes  and 
cascara  sagrada.  Drugs  administered  for  chronic  constipation  should  be 
employed  at  night,  so  that  the  quietude  of  the  patient  will  allow  the  drug  to 
pass  slowly  over  the  whole  mucosa.  I  am  of  the  opinion  that  the  addition  of 
belladonna  to  cathartic  pills  is  superfluous,  and  therapeutically  only  adds 
injury  to  insult.  Tha  cathartic  insults  the  mucosa,  while  the  belladonna 
injures  it,  by  attempting  to  deceive  it  by  anesthesia — both  enemies  to  the 
normal,  peaceful,  mucosa  life. 

The  beneficial  effects  of  mineral  waters,  which  generally  depend  upon 
the  contained  glauber  and  epsom  salts,  are  only  secured  by  long-continued 
use.  Of  the  two  forms  of  drugs,  pills  or  liquids,  given  for  constipation,  the 
pill  form  is  the  superior  one,  because  it  works  slowly,  and  thus  imitates 
nature  more  closely.  Nature  always  resents  violent  insults,  with  evil  conse- 
quences. Nature  itself  is  a  bundle  of  habits,  and  if  we  are  to  be  successful, 
we  must  imitate  her  methods.  Hence,  we  must  employ  for  constipation,  diet, 
fluid,  exercise,  physical  procedure,  and,  lastly,  adjuvant  cathartics — we  must 
study  the  sympathetic  nervous  system. 

The  treatment  of  constipation  does  not  consist  in  searching  after  and 


NEUROSIS  BASIS  OF  CONSTIPATIOh 


373 


administering  drugs,  but  rather  in  the  avoidance  of  their  use.  We  may  first 
say  that  constipation  is  not  curable  by  any  planless  method,  nor  by  any 
planned  method  imperfectly  executed,  while  there  may  really  be  non-remov- 
able anatomical  conditions  causing  the  difficulty.  Planless  prescribing  of 
cathartics  is  worse  than  useless.  The  head  and  front  of  all  therap*  u1  n 
constipation  is  due  to  an  original,  abnormal,  nervous  suspension  of  the  .  •  ri- 
stalsis  of  the  fecal  reservoir.  This  concerns  us  and  our  therapeutics;  though 
we  may  find  difficulty  in  excluding  congenital  defects,  such  as  atony  of  the 
bowel  wall,  or  constipation  due  to  dislocated  viscera.     Is  the  constipation,  as 


X-RAY  OF  DUCTUS  BILIS  ET  DUCTUS  PANCREATICUS  OF  HORSE 
Fig.  84.     Bile  and  pancreatic  ducts  of  horse  which  possess  no  cholecyst  or  gall  bladder. 

Dunin  suggests,  a  mere  symptom  of  neurasthenia?  If  our  original  proposition 
be  true,  viz.,  that  constipation  is  a  neurosis  of  the  fecal  reservoir,  cathartics 
are  not  only  useless,  but  harmful. 

In  constipation  we  should  attempt  to  cure  the  neurosis,  the  neurasthenia, 
when  the  constipation  will  disappear.  The  moral  part  of  the  patient  should 
receive  attention,  for  often  there  is  far  more  in  the  suggestions  added  to 
medicine,  than  the  remedies  themselves  can  supply.  If  constipation  depends 
on  suspension  of  peristalsis,  either  from  muscular  atony  or  deficient  innerva- 
tion, it  is  plain  how  malpractice  resides  in  the  use  of  cathartics.     Fhysical 


374  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

procedures  must  above  all  be  employed  in  muscular  atony,  or  defective  inner- 
vation, of  the  fecal  reservoir.  In  the  treatment  of  constipation  it  may  aid  to 
determine  the  etiologic  cause,  as  atonic  constipation,  associated  muscular 
atrophy;  neurotic  constipation,  associated  with  disorders  of  the  cerebro-spinal 
axis,  or  the  sympathetic  (tabes,  lead  poisoning) ;  metabolic  constipation,  asso- 
ciated with  disordered  metabolism,  as  excessive  obesity,  sweating,  diabetes, 
anemia;  trophic  constipation,  associated  with  subjects  ingesting  excessive 
meats,  or  other  dietetic  errors. 

Suggestion. — I  wish  here  to  emphasize  the  subject  of  suggestion  in  the 
control  or  cure  of  constipation.  The  control  of  mind  over  matter  has  no 
uncertain  sound  in  the  aid  to  cure  constipation.  The  psychic  effect  of  a 
well-directed  suggestion  is  often  effective  in  stimulating  peristalsis  for  regular 
stated  times  for  evacuation.  For  example,  tell  a  patient,  definitely,  to  go  to 
stool  after  breakfast,  as  the  hot  coffee  stimulates  the  bowel  to  action.  He 
will  not  only  concentrate  his  mind  on  the  function,  but  will  cultivate  his 
mind  for  a  definite  period  for  evacuation,  which  I  consider  of  vast  value. 
Occasionally,  particularly  in  neurotics,  this  will  effect  a  cure.  With  the 
suggestion  for  a  daily  evacuation  at  a  stated  period  should  be  combined 
simple  convenient  remedies,  as  gymnastic  exercise,  special  diet,  in  order  that 
the  patient  may  observe  cause  and  effect. 

Dietetic  Stivunary — Quality  of  foods,  quantity  of  fluid,  chemical  compo- 
sition, are  important  considerations,  (a)  Food  must  possess  sufficient  variety 
(mixed)[in  quantity,  quality,  chemical  composition,  and  be  ingested  at  regular 
intervals.  The  food  should  be  mixed,  however,  possess  sufficient  indigestible 
matter  to  leave  ample  residue  to  stimulate  peristalsis  (and  hence  absorption, 
sensation  and  secretion).  An  excessive  amount  of  coarse,  indigestible  food 
will  result  in  an  excessive  fecal  residue,  which  excessively  stimulates  peristal- 
sis, absorption,  secretion  and  sensation — resulting  in  muscular  fatigue 
and  defective  sensibility  of  the  mucosa — consequently,  reflex  action  is 
impaired. 

(b)  Ample  fluids,  at  regular  intervals,  should  be  ingested.  For  a  person 
of  one  hundred  and  fifty  pounds  five  pints  is  required  to  supply  the  bodily 
waste  (i.  e.,  tractus  intestinalis,  respiratorius,  urinarius,  perspiratorius),  eight 
ounces  should  be  drunk  every  two  hours  for  six  times  daily.  Fecal  matter  is 
about  seventy-five  per  cent  fluid  and  twenty-five  per  cent  solid.  The  value 
of  fluids  for  the  tractus  intestinalis  is  evident,  because  in  hot  weather,  with 
consequent  vigorous  action  of  the  tractus  perspiratorius,  constipation  results. 
The  chief  value  of  mineral  water  is  the  quantity  drank.  Excessive  fluids 
deteriorate  digestion. 

(c)  Foods  should  possess  chemical  qualities.  Carbohydrates  produce 
acidity,  nitrogenous  foods  alkalinity,  and  mixed  foods  neutrality  of  the  digest- 
ive tract.  Evacuation  of  the  tractus  intestinalis  depends  on:  (a)  Sufficient 
volume  of  feces,  (b)  sufficient  volume  of  fluid  contents,  (c)  the  presence  of 
substances  which  act  as  a  chemical  irritant  to  peristalsis.  Dr.  Walter 
Baumgarter  attempted  to  devise  a  substance  which  would  not  only  be  difficult 
to  absorb,  but  would  retain  its  watery  contents  (be  hygroscopic).     He  admin- 


FOR  CONSTIPATION— VISCERAL  DRAINAGE  375 

istered  eight  grains  of  the  dry,  shredded  agar-agar  three  times  daily,  whence 
he  found  the  stool  increased  in  volume  and  watery  contents. 

Visceral  Drainage.  —  I  wish  here  to  introduce  a  method  of  treatment  for 
constipation  which  I  have  employed  successfully  for  a  score  of  years.  I  have 
termed  it  "Visceral  Drainage." 

One  of  the  most  important  principles  in  surgery  is  ample  drainage  of 
(septic)  wounds.  One  of  the  most  important  principles  in  internal  medication 
is  ample  drainage  of  the  viscera.  Fifteen  years  of  the  application  of  what  I 
term  "Visceral  Drainage,"  in  dispensary  and  private  practice,  has  afforded  me 
ample  time  to  observe  its  extensive  application  and  utility.  Viscera  are 
drained  by  several  means;  however,  the  two  most  rational  and  practical 
methods  of  visceral  drainage  are:  (A)  by  fluids;  (B)  by  appropriate  foods. 
The  viscera  are  the  sewers  of  the  body,  and  their  proper  drainage  and  flushing 
is  the  key  to  health  and  its  maintenance.  Draining  the  viscera  drains  and 
flushes  the  internal  tissue  and  tissue  spaces. 

The  muscles  are  powerful  regulators  of  circulation  (as  exercise),  hence 
there  is  stimulation,  which  increases  the  tone  of  vessels,  blood  currents,  and 
prevents  consequent  congestion  (the  arch  enemy)  in  chronic  disease.  The 
myometrium,  like  living  ligatures,  control  the  blood  supply  of  the  uterus. 
Visceral  drainage  initiates  and  maintains  peristalsis,  which  controls  visceral 
blood  supply.  A  stimulus — whether  it  be  an  icicle,  red-hot  iron,  electricity, 
massage,  exercise — is  what  the  flaccid  muscles  require  to  maintain  peristalsis, 
which  controls  secretion  and  absorption.  The  endometrium  flooded  with 
excessive  secretion  (leucorrhea)  rapidly  assumes  its  normal  secretion  by  stim- 
ulating the  myometrium  (by  douche,  massage,  etc.). 

A — Visceral  Drainage  by  Fluids. — The  best  diuretic  is  water.  It  is  the 
greatest  eliminant.  A  man  of  one  hundred  and  fifty  pounds  should  produce 
daily  some  forty-five  ounces  of  urine.  If  we  calculate  the  loss  of  fluid  by  the 
tractus  perspiratorius,  tractus  intestinalis,  and  tractus  respiratorius,  it  will 
require  about  five  pints  of  the  ingested  fluid  to  produce  daily  forty-five  ounces 
of  urine.  Many  subjects  do  not  drink  over  three  pints  of  fluid  daily,  and  that 
is  performed  chiefly  at  meal  time,  not  only  burdening  the  tractus  intestinalis 
with  the  meal,  but  fluid  also.  Large  numbers  of  "people  drink  insufficiently 
and  suffer  consequent  oliguria.  Such  subjects  are  burdened  with  waste-laden 
blood,  inflicting  irritation  and  trauma  on  the  nerve  periphery.  They  are  in 
conflict  with  their  own  secretions.  Many  women  oppose  free  drinking,  from 
the  idea  that  it  creates  fat.  Ample  quantities  of  fluid,  at  regular  intervals,  is 
the  safety  valve  of  health  and  capacity  for  mental  or  physical  labor.  Ample 
fluids  not  only  flush  the  sewers  of  the  body,  but  wash  the  internal  tissues 
and  tissue  spaces,  relieving  waste-laden  blood.  The  soluble  matter  and  salts 
are  not  only  dissolved  (preventing  trauma  and  infection)  and  eliminated,  but 
the  insoluble  matter  and  salts  are  flooded  from  the  system,  relieving  waste- 
laden  blood  by  such  powerful  streams  of  fluid  that  calculus  is  not  liable  to  be 
formed. 

For  many  years  I  have  diluted  the  urine,  increased  its  volume  (conse- 
quently, increased  ureteral  peristalsis),  and  clarified  it  by  administering  eight 


376  THE  ABDOMIXAL  AND  PELVIC  BRAIN 

ounces  of  one-half  or  one-quarter  normal  salt  solution,  six  times  daily.  I 
have  made  sodium  chloride  tablets  (twelve-grain,  each  with  flavor).  The 
patient  places  on  the  tongue  a  half  tablet  (NaCl),  and  drinks  a  glass  of  water 
(better  hot)  before  each  meal.  This  is  repeated  in  the  middle  of  the  forenoon 
(ten  a.  M.X  middle  of  the  afternoon  (three  p.  m.),  and  at  bedtime  (nine  p.  m.). 
The  patient  thus  drinks  three  pints  of  (one-quarter  to  one-half)  normal  salt 
solution  daily.  This  practically  renders  the  urine  normal,  and  acts  as  ample 
prophylaxis  against  the  formation  of  urinary,  hepatic,  pancreatic,  fecal  calcu- 
lus, and  sewers  the  bod}7  of  waste  material.  The  formation  of  a  calculus  can 
not  occur  when  ample  fluid  bathes  the  glandular  exit  canals.  In  deficient 
fluid,  crystals  form  calculus  with  facility.  The  maximum  concentrated  solu- 
tion of  urine,  bile,  or  pancreatic  juice,  tends  to  crystalize  with  vastly  more 
facility  than  dilute  urine,  bile,  and  pancreatic  juice.  In  "'Visceral  Drainage" 
single  crystals,  on  first  formation,  are  rapidly  floated  with  facility  when  ample 
fluids  are  present;  while  in  small  quantities  of  fluid,  with  weak  stream,  the 
crystals  tend  to  lodge,  accumulate,  and  form  calculus.  Oliguria  is  a  splendid 
base  for  calculus  formation. 

If  parenchymatous  nephritis  exists,  the  NaCl  should  not  be  administered, 
as  it  excessively  stimulates  the  renal  parenchymatous  cells.  In  such  cases 
administer  the  water  only. 

For  over  ten  years  I  have  been  using  sodium  chloride  tablets,  more  or 
less,  in  my  practice.  During  that  time  some  practical  clinical  views  have 
been  gained,  and  repeated  so  frequently  that  they  have  become  established, 
I  think,  beyond  the  shadow  of  a  doubt.  The  following  propositions  have 
been  repeatedly  demonstrated  so  many  hundreds  of  times  during  the  last  ten 
years  in  our  clinics  and  surgical  operations,  that  I  shall  consider  them  estab- 
lished until  otherwise  disproven: 

1.  Sodium  chloride  (in  one-half  to  one-quarter  normal  physiological  salt 
solution)  is  a  powerful  stimulant  to  the  renal  epithelium  (tractus  urinarius). 

2.  Sodium  chloride  should  not  be  administered  in  parenchymatous  neph- 
ritis (not  even  in  food),  as  it  exacerbates  and  irritates  the  diseased,  inflamed 
parenchymatous  cells. 

3.  Sodium  chloride  (in  one-half  to  one-quarter  normal  physiologic  salt 
solution)  is  a  vigorous  stimulant  to  the  epithelium  of  the  tractus  intestinalis, 
inducing  fluid  to  flow  into  the  lumen,  stimulating  peristalsis  and  softening 
the  feces. 

4.  Sodium  chloride  increases  absorption,  secretion  and  peristalsis  of  the 
tractus  intestinalis.  It  is  an  excellent  remedy  to  quench  thirst  after  peritonot- 
omy,  by  copious  gradual  rectal  irrigations  fallowing  a  pint  in  forty-five  min- 
utes to  flow  over  the  sigmoid  and  rectal  mucosa). 

5.  The  administration  of  eight  ounces  of  one-half  to  one-quarter  normal 
physiologic  salt  solution  (better  hot),  every  two  hours,  for  six  times  daily, 
will  increase  the  quantity  and  clarify  the  urine,  eliminate  its  color,  making  it 
appear  almost  like  spring  water  in  three  to  five  days.  The  feces  will  be 
softened,  increase,  in  volume,  inciting  peristalsis. 

6.  Sodium  chloride  is  a  vigorously  active  stimulant  to  glandular  epithe- 


VISCERAL  DRAINAGE  BY  FOODS  377 

Hum  (as  that  of  the  tractus  urinarius,  tractus  intestinalis,  tractus  cutis,  sali- 
vary, hepatic  and  pancreatic  glands). 

7.  The  effect  of  the  one-half  to  one-quarter  normal  physiological  salt 
solution  (six  times  daily)  on  the  tractus  urinarius  is  to  increase  the  quantity 
and  clarify  the  urine. 

B — Visceral  Drainage  by  Foods. — To  drain  the  viscera  by  proper  foods 
may  sound  paradoxical,  but  the  four  grand  functions  of  the  tractus  intestinalis 
— peristalsis,  absorption,  sensation  and  secretion — are  maintained,  practically, 
by  food  alone.  The  appropriate  food  produces  the  appropriate  degree  of 
peristalsis,  and  the  quantity  of  intestinal  secretions,  which  is  absolutely 
essential  for  visceral  drainage — and  to  prevent  constipation.  The  food  that 
will  induce  proper  peristalsis,  stimulate  sensation,  absorption  and  secretion, 
is  that  which  leaves  a  large  residue  to  stimulate  the  distal  bowel,  enteron  and 
colon,  such  as  cereals,  oils,  and  vegetables.  Peristalsis  is  necessary  for  secre- 
tion, for  peristalsis  massages  the  secretory  glands  in  the  tractus  intestinalis, 
enhancing  secretion,  e.  g. ,  the  rational  treatment  of  excessive  uric  acid  in  the 
urine  consists  of  administering  food  that  contains  elements  to  produce  basic 
combinations  with  uric  acid,  forming  urates  (usually  sodium),  which  are  freely 
soluble.  This  will  diminish  the  free  uric  acid  in  the  urine.  Excessive  uric 
acid  in  the  urine  is  an  error  in  metabolism.  The  question  of  diet  to  deter- 
mine is:  (a)  What  kind  of  food  causes  the  calculus-producing  material  in  the 
urine?  (b)  What  kind  of  food  influences  the  solubility  of  the  calculus-produc- 
ing material  in  the  urine? 

1.  The  meat-eater  is  the  individual  with  the  maximum  quantity  of  free 
uric  acid  in  the  urine.  Flesh  is  rich  in  uric  acid.  Hence,  in  excess  of  uric 
acid  in  the  urine,  flesh  (meat,  fish  and  fowl,  are  all  about  equal  in  power  to 
produce  uric  acid)  should  be  practically  excluded,  because  it  increases  free 
uric  acid  in  the  urine.  Flesh  eaters  have  uric  acid  stone,  vegetarians  have 
phosphate,  oxalate  stone. 

Generally,  the  subject  who  suffers  from  uric  acid  is  a  generous  liver, 
liberally  consuming  meat  and  highly-seasoned  foods,  indolent  and  sedentary 
persons,  and  alcoholic  indulgers.  Thirty-three  per  cent  of  uric  acid  is  nitro- 
gen. Uric  acid  is  derived  from  the  nuclei  that  form  a  constituent  of  all  cell 
nuclei,  and  which  are  taken  in  the  body  as  a  food.  Beef  bouillon  may  be  cell 
administered,  because  the  extract  matters  in  it  will  scarcely  increase  the  uric 
acid.     A  general  meat  diet  largely  increases  the  free  uric  acid  in  the  urine. 

2.  The  food  should  contain  matters  rich  in  sodium,  potassium  and 
ammonium,  which  will  combine  as  bases  with  uric  acid,  producing  alkaline 
urates,  which  are  perfectly  soluble  in  the  urine.  These  typic  foods  are  the 
vegetables,  which  not  only  render  the  necessary  alkalies  to  reduce  and  trans- 
form the  free  uric  acid  into  resulting  soluble  urates,  but  leave  an  ample  resi- 
due to  cause  active  intestinal  peristalsis,  aiding  in  the  evacuation  through  the 
digestive  tract.  Hence,  the  patient  should  consume  large,  ample  quantities 
of  cabbage,  cauliflower,  beans,  peas,  radishes,  turnips,  and  spinach  in  order 
that  the  sodium,  potassium,  and  ammonium  existing  in  the  vegetables  may 
combine,  as  bases,  with  free  uric  acid  in  the  urine,  producing  soluble  urates, 


378  THE  ABDOMINAL  AND  PELVIC  BRAIN 

thus  diminishing  free  uric  acid.  A  vegetable  diet  diminishes  the  free  uric 
acid  in  the  urine  thirty-five  per  cent  less  than  a  meat  diet.  Again,  the  admin- 
istration of  eggs  and  milk  (lactoalbumin)  limits  the  production  of  uric  acid. 
The  most  rational  advice  is  to  order  the  subject  to  live  on  a  mixed  diet,  con- 
suming the  most  of  that  kind  of  food  which  lessens  the  uric  acid  in  the  urine 
— vegetables. 

If  the  appropriate  food  is  so  valuable  in  "visceral  drainage  treatment"  of 
the  typical  uric  acid  subject, the  appropriate  food  selected  for  subjects  of  biliary 
and  pancreatic  calculus  will  be  relatively  as  useful.  The  foods  that  make 
soluble  basic  salts  with  secretions  should  be  selected.  Besides,  the  selection 
of  appropriate  food  is  frequently  amply  sufficient  to  drain  the  intestinal  tract 
to  prevent  constipation.  It  is  true,  foods  alone  are  not  a  complete  substitute 
for  fluids,  but  vast  aid  in  visceral  drainage  may  be  accomplished  by  adminis- 
tering food  containing  considerable  indigestible  matter,  so  that  a  large  fecal 
residue,  saturated  with  fluid,  will  stimulate  the  intestines,  especially  the  colon, 
to  continuous  vigorous  activity,  maintaining  the  maximum  action  of  the  four 
grand  functions — peristalsis,  absorption,  sensation  and  secretion.  For  many 
years  I  have  treated  subjects  with  excess  of  uric  acid  in  the  urine  by  adminis- 
tering an  alkaline  laxative  tablet  in  fluid.  The  tablet  is  composed  of: 
Cascara  sagrada,  one-fortieth  of  a  grain;  NaHC02  one  grain;  socotrine  aloes, 
one-third  grain;  KHCO3,  one-third  grain;  MgS04,  two  grains.  The  tablet 
is  used  as  follows:  One-sixth  to  one  tablet  (or  more,  as  required,  to  move  the 
bowels  once  daily)  is  placed  on  the  tongue  before  meals,  and  followed  by 
eight  ounces  of  water  (better  hot).  At  ten  A.  m.,  three  p.  m.,  and  bedtime, 
one-sixth  to  one  tablet  is  placed  on  the  tongue,  and  followed  by  a  glassful 
of  fluid.  In  the  combined  treatment  the  sodium  chloride  tablet  and  alkaline 
tablet  are  both  placed  on  the  tongue  together.  This  method  of  treatment 
furnishes  alkaline  bases  (sodium  and  potassium  and  ammonium)  to  combine 
with  the  free  uric  acid  in  the  urine,  producing  perfectly  soluble  alkaline 
urates,  and  materially  diminishing  the  free  uric  acid.  Besides,  the  alkaline 
laxative  tablet  increases  the  peristalsis,  absorption,  sensation  and  secretion  of 
the  intestinal  tract,  aiding  evacuation.  I  have  termed  the  sodium  chloride 
and  the  alkaline  laxative  method  the  "visceral  drainage  treatment."  The 
alkaline  and  sodium  chloride  tablets  take  the  place  of  the  so-called  mineral 
waters.  Our  internes  have  discovered  that  on  entering'  the  hospital  the 
patient's  urine  presents  numerous  crystals  under  the  microscope.  However, 
after  following  the  "visceral  drainage  treatment"  for  a  few  days  crystals  can 
not  again  be  found.  The  hope  of  removing  a  formed  localized  ureteral,  or 
other,  calculus,  lies  in  securing  vigorous  ureteral  or  other  duct  peristalsis  with 
a  powerful  ureteral  or  other  duct  stream,  aided  by  systematic  massage  over 
the  psoas  muscle  and  per  vaginam.  Subjects  afflicted  with  excess  of  uric  acid 
in  the  urine,  or  other  form  of  calculus,  need  not  make  extended  sojourns  to 
watering  places,  nor  waste  their  time  at  mineral  springs,  nor  tarry  to  drink 
the  hissing  Sprudel,  for  they  can  be  treated  successfully  in  a  cottage,  or  in  a 
palace.  The  treatment  of  a  uric  acid  or  other  calculus  consists,  therefore,  in 
the  regulation  of  food  and  water.     It  is  dietetic.     The  control,  relief  and  pro- 


TRLl.  ITMENT  OF  CONSTIPATION  379 

phylaxis  of  uric  acid  diathesis  or  tendency  to  other  calculus  formation,  is  a 
lifelong  process.  When  the  uric  acid  or  other  calculus  has  passed  spontane- 
ously the  patient  does  not  end  his  treatment,  but  should  pursue  a  constant 
systematic  method  of  drinking  ample  fluids  at  regular  intervals,  and  eat  food 
which  contains  bases  to  combine  with  the  free  uric  acid  or  other  compounds 
producing  soluble  urates  or  other  soluble  compounds. 

I  continue  this  treatment  for  weeks,  months,  and  the  results  are  remark- 
ably successful.  The  urine  becomes  clarified,  like  spring  water,  and  increased 
in  quantity.  The  tractus  intestinalis  becomes  freely  evacuated  regularly 
daily.  The  blood  is  relieved  of  waste-laden  and  irritating  material.  The 
tractus  cutis  eliminates  freely,  and  the  skin  becomes  normal.  The  appetite 
increases,  the  sleep  becomes  improved,  the  feelings  become  hopeful.  The 
sewers  of  the  body  are  well  drained  and  flushed. 

Chronic  constipation  is  compensatory,  for  during  this  condition  a  greater 
portion  of  the  food  ingested  undergoes  digestion  and  absorption  than  in  the 
normal  individual,  and  consequently  the  fecal  residue  is  more  limited.  By 
reason  of  the  fecal  residue  there  is  less  material,  and  a  less  favorable  medium 
for  the  development  of  bacteria,  in  consequence  of  which  less  irritating  prod- 
ucts occur,  on  which  the  stimulus  to  the  required  peristalsis,  more  or  less, 
depends.  The  varying  pressure  of  the  abdominal  walls  on  the  viscera  modi- 
fies the  viscera  circulation  in  quantity  and  rapidity.  The  visceral  vessels, 
especially  the  abdominal,  constitute  a  kind  of  hemogenous  reservoir  for  sur- 
plus of  blood,  by  which  general  blood  pressure  may  be  regulated  among  vis- 
cera. The  dilatation  of  abdominal  visceral  vessels  may  be  so  great  that  cer- 
ebral anemia  may  advance  to  a  state  of  syncope,  collapse,  or  shock.  We 
may  yet  learn  to  apply  Bier's  congestion,  or  blood  controlling  methods,  to 
cure  constipation  by  practicing  on  the  sphincters.  Abdominal  visceral  circu- 
lation must  not  only  be  controlled  for  maximum  digestion  (which  is  normal 
absorption,  secretion,  sensation  and  peristalsis  of  the  enteron),  but  also  for 
maximum  colon  peristalsis,  which  is  required  for  normal  evacuation.  We 
know  that  mental  or  physical  excitement  at  meals  modifies  digestion  (which 
means  modification  of  circulation).  Dilatation  of  the  blood  vessels  in  the 
splanchnic  area  lowers  the  blood  pressure,  increases  rate,  rhythm  and  force 
of  pulse.  Maximum  circulation  in  abdominal  organs  is  conducive  to  maximum 
absorption,  secretion,  sensation  and  peristalsis.  Pathologic  increase  of 
circulation  in  the  abdominal  viscera  leads  to  corresponding  activity  of 
unction.  This  lends  a  clue  to  treat  constipation.  Increased  secretion  of 
the  glands  of  the  tractus  intestinalis,  in  consequence  of  nervous  influence,  is 
well  known  (which  refers  to  circulation). 

Visceral  congestion  (chronic)  leads  to  relaxation  of  visceral  supports. 
Interruption  of  circulation  (anemia)  leads  to  visceral  spasm,  colic.  Spasm 
of  the  muscle  of  the  digestive  apparatus  produces  colic.  There  can  be  slight 
doubt,  clinically,  that  spasmodic  (anemic)  constipation  occurs — e.  g.,  lead  or 
(anemic)  colic.  In  the  practice  of  medicine  the  vascular  area  governed  by 
the  splanchnics  will  be  more  utilized  in  therapeutics.  For  example,  the  head- 
aches,  dizziness,  faintness,   syncope,   vertigo,    which   appear   and   disappear 


380  THE  ABDOMINAL  AND  PELVIC  BRAIN 

suddenly  without  sufficient  time  for  autointoxication,  infections,  are  likely  to 
produce  circulatory  changes  in  the  splanchnic  and  producing  cerebral  anemia. 
So,  also,  cold  hands  and  feet,  aching  pains  in  limbs,  neuralgic  pains  in  various 
bodily  regions,  may  be  due  to  excessive  tendency  of  blood  to  the  splanchnic 
area.  Irritation  of  the  nerves  of  the  splanchnic  vessels  are  transmitted  to 
distant  regions,  leading  to  spasms  (anemia,  ischemia)  of  vessels,  and  pain, 
cramps  in  muscles.  This  may  explain  the  frequent  colic,  cramps,  of  neurotic 
subjects. 

Circulatory  disturbances  in  the  tractus  intestinalis  should  not  be  mistaken 
for:  (a)  Mechanical  irritation  from  coarse  food,  (b)  chemical  irritation 
from  ingested  irritants  (as  acids,  spices,  meats),  (c)  pathologic  physiology, 
as  excessive,  deficient  or  disproportionate  secretion  and  consequent  fermen- 
tation (microbic).  The  dilatation  of  the  splanchnic  vessels  are  physiologically 
opposed  to  the  dilatation  of  the  peripheral  vessels,  and  since  the  splanchnic 
vesstls  are  controlled  by  a  nervous  mechanism,  it  may  be  hoped  that  a  definite 
therapeutic  remedy  will  appear  that  will  contract,  or  dilate,  these  visceral 
vessels.  Since  physiologic  antagonism  exists  between  the  splanchnics  and 
peripheral  vessels,  agents  which  dilate  the  splanchnics  contract  the  peripheral 
vessels,  and  vice  versa.  The  dilatation  of  the  anal  sphincter  dilates  and 
flushes  the  peripheral  capillaries  with  it,  contracts  the  splanchnic  vessels. 
The  peripheral  vessels  may  be  dilated  by  mechanical  means,  as  massage, 
hypertrophy,  a  hot  and  cold  water  chemical  irritation,  as  mustard,  turpentine. 

Normal  evacuations  of  the  tractus  intestinalis  require  an  ample  stream 
of  fresh  blood  irrigating  the  intestinal  tract,  which  is  accomplished  by  admin- 
istering food  with  indigestible  remnants. 

The  tendency  of  the  blood  stream  to  an}'  other  visceral  tract  than  the 
intestinal,  lessens  the  peristalsis,  absorption,  sensation  and  secretion,  favor- 
ing constipation. 

In  pubertas,  menstruation,  gestation  or  chronic  genital  inflammation, 
the  circulation  tends  toward  the  genitals,  robbing  the  tractus  intestinalis  of 
blood,  inducing  constipation. 

In  the  puerperium  the  patient  should  exercise,  employ  gymnastics,  mas- 
sage the  abdominal  muscles,  ingest  foods  which  have  a  residue,  and  limit  the 
enforced  rest  to  a  week,  in  order  to  restore  muscular  action  and  visceral  cir- 
culation, especially  the  intestinal. 

Chronic  inflammation,  tumor,  irritation  on  any  one  visceral  tract,  tends 
to  unbalance  the  normal  circulation  in  all  other  visceral  tracts — inducing  con- 
stipation— hence  to  improve  constipation,  remove  the  disease  or  disturbance 
in  other  visceral  tracts. 

Any  defective  segment  of  the  tractus  intestinalis  (gastrium,  enteron, 
colon)  should  be  repaired,  and  any  defective  function  (peristalsis,  secretion, 
sensation  and  absorption)  should  be  restored. 

A  subject  of  one  hundred  and  fifty  pounds  requires  five  pints  of  fluid  daily 
to  produce  ample  visceral  circulation  (to  supply  the  physiologic  demands  of 
the  tractus  urinarius,  tractus  cutis,  tractus  respiratorius,  tractus  intestinalis). 

Vegetables  and  graham  bread  (which  should  contain  the  flour,  shorts  and 


TREATMENT  OF  CONSTIPATION  381 

bran)  leave  ample  residue  to  stimulate  the  tractus  intestinalis,  inviting  a  vigor- 
ous circulation. 

Rectal  injections  and  colonic  irrigation  should  not  be  employed  fre- 
quently, as  the  rectum  may  lose  its  sensitiveness,  becoming  so  blunted  in 
sensibility  that  it  will  forget  to  act  when  fecal  matter  is  present.  Clysters  of 
oil  are  excellent  remedies  to  soften  fecal  masses. 

Persistent  use  of  galvanic  and  faradic  electricity  produces  favorable 
effects  on  constipation,  the  electricity  energizes  the  abdominal  walls  and 
intestinal  muscles.  However,  I  can  not  report  such  favorable  results  as 
those  of  C.  V.  Wild,  in  his  excellent  essay,  "Die  Verheutung  und  Bekandlung 
der  Chronischen  Verstopfung  bei  Frauen  und Madchen." 

Constipation,  if  pursued  by  both  patient  and  physician,  with  favorable 
will  and  energy,  is  practically  a  curable  disease. 


CHAPTER   XXX. 

SHOCK. 

By  Lucy  Wane,  A.  B.,  M.  D.,  Head  Surgeon  of  Mary  Thompson  Hospital  for  Women  and  Children. 

Shock  in  its  widest  significance  covers  the  whole  of  medicine.  From 
the  slightest  physical  traumatism  or  the  lightest  mental  depression  to  the 
most  profound  impressions  on  the  vasomotor  centers  causing  instantaneous 
death,  the  difference  is  only  one  of  degree,  the  phenomena  being  the  same. 
It  would  therefore  be  impossible  in  one  short  chapter  to  follow  out  the  sub- 
jects in  all  its  various  ramifications  in  the  field  of  medicine  and  surgery  and  it 
must  suffice  to  treat  it  in  a  comprehensive  manner  as  an  affection  primarily 
of  the  nervous  system  with  the  secondary  involvement  of  the  vascular  system 
as  a  whole. 

HISTORY. 

While  it  is  only  during  the  last  fifty  years  that  any  scientific  experiments 
have  been  made  with  a  view  toward  discovering  the  pathology  of  shock,  as 
early  as  1826,  Travers,  in  his  work  on  Constitutional  Irritation,  gave  an 
exact  description  of  the  phenomena  of  shock.  The  first  treatise  on  the  sub- 
ject I  have  been  able  to  find  was  published  in  1868,  by  Edwin  Morris,  F.  R. 
C.  S.  In  this  he  states  that  the  first  mention  of  shock  in  medical  literature 
was  in  1819,  in  the  works  of  F.  Hennen  and  Guthrie,  writing  on  military 
surgery.  Morris  considered  death  from  shock  due  to  functional  disturbance 
of  the  brain,  the  heart  being  affected  only  secondarily.  He  places  no 
emphasis  on  the  part  played  by  the  sympathetic  system  and  mentions  this 
only  once  incidentally  as  the  par  vagum  and  says  it  connects  the  spinal  cord, 
brain  and  heart.  He  treats  of  shock  under  two  headings,  surgical  and  shock 
from  mental  causes.  He  gives  the  classical  symptoms  and  concludes  that 
shock  is  due  to  paralysis  of  the  nervous  system  destroying  the  normal 
function  of  the  brain  and  withdrawing  the  nervous  stimulus  from  the  heart. 
He  confuses  shock  and  concussion  of  the  brain,  but  warns  against  confus- 
ing this  condition  with  extravasation  in  injuries  to  the  brain. 

I  have  given  a  brief  synopsis  of  his  brochure  because,  being  written  in  a 
comprehensive  manner  and  as  late  as  1868,  we  may  assume  that  it  contains 
all  that  was  known  on  the  subject  up  to  that  date.  Previous  to  this  mention 
was  made  of  the  subject  in  Cooper's  "Medical  Dictionary"  in  1838  and  in 
Copeland's  "Dictionary"  in  1858.  In  Cooper's  "Surgical  Dictionary,"  pub- 
lished in  1859,  however,  there  is  no  mention  of  shock. 

One  of  the  most  interesting  landmarks  in  the  history  of  the  literature  on 
shock  is  Davey's  work  published  in  1858.  Under  the  heading  of  "Syncope" 
he  gives  a  long  dissertation  on  the  phenomena  of  shock,  although  this  word 
is  used  only  once,  and  he  foreshadows  both  the  present  theory  of  the  pathol- 
ogy and  the  latest  treatment  as  demonstrated  by  the  experiments  of  Dr.  Geo. 

382 


SHOCK  3S3 

C.  Crile  and  others  in  his  observations  on  collapse  after  labor  and  the  too 
rapid  escape  of  the  ascitic  fluid  in  paracentesis  abdominis.  "I  am,  however, 
confident,"  he  says,  "that  the  bona  fide  explanation  of  the  fact  is  to  be 
sought  for  in  loss  of  the  long-accustomed  adaptation  or  relationship  between 
the  containing  and  contained  parts  of  the  abdomen,  whereby  the  ganglionic 
nervous  system  is  at  its  very  center  more  or  less  paralyzed." 

He  says  he  has  no  doubt  that  the  many  cases  of  sudden  death  attributed 
to  cerebral  hemorrhage,  disease  of  the  heart,  air  embolism,  etc.,  are  in 
reality  caused  by  "syncope,"  as  he  terms  it,  and  that  the  cause  is  to  be 
found  in  the  fact  that  "the  ganglionic  nervous  system  has  been  drawn  on  so 
largely  by  the  cerebro-spinal  and  muscular  systems  that  there  is  nothing 
remaining  for  the  thoracic  and  abdominal  viscera — no  stimulus  left  for  the 
vital  organs."  Mr.  Paget,  writing  in  1862,  gives  the  phenomena  and  treat- 
ment. Later  Brown-Sequard  and  Savory  (1870)  made  the  valuable  discovery 
of  the  pathology  of  shock.  Brown-Sequard  announced  as  the  result  of  his 
work  the  theory  of  anaemia  of  the  cerebral  centers  due  to  a  more  or  less  per- 
sistent contraction  of  the  capillaries  through  the  vasomotor  center.  The 
experiments  of  Goltz  on  frogs  was  the  most  important  work  done  in  this 
direction  until  the  last  few  years.  With  Brown-Sequard  and  Savory,  he  held 
to  the  theory  of  cardiac  paralysis.  He  showed  that  through  the  inhibitory 
influence  exerted  upon  the  splanchnics,  the  abdominal  vessels  were  suddenly 
dilated.  In  Quain's  "Medical  Dictionary"  (1884)  is  a  statement  of  the 
status  of  the  subject  of  shock  at  that  date  and  concludes:  "For  the  pres- 
ent we  may  thus  accept  as  the  most  plausible  interpretation  of  the  symptoms 
of  shock  a  sudden  dilatation  of  the  abdominal  vessels,  attributable  to  an 
inhibitory  influence  exerted  upon  the  splanchnics,  through  the  medium  of  a 
special  reflex  center."  Not  much  has  been  added  to  this  explanation  of  the 
real  pathology  of  shock,  but  valuable  experiments  have  been  made  in  recent 
years  in  the  line  of  pathology,  and  some  working  toward  a  more  rational 
treatment  by  Geo.  C.  Crile,  Robert  Dawbarn,  Harvey  Cushing,  Eugene 
Boise,  Guy  C.  Kennaman,  John  H.  Packard  and  others  of  our  own  pro- 
fession. In  the  extensive  surgical  encyclopedia  edited  by  Dupley  and  Reclus 
in  1890,  "Traite  de  Chirurgie, "  is  the  statement  that  it  is  only  during  the  last 
twenty  years  that  shock  has  been  studied  in  France  and  that  the  French,  in 
acknowledging  the  origin  of  the  researches  in  this  subject,  often  use  the 
English  orthography,  although  having  a  legitimate  word  in  their  own  lan- 
guage, "choc."  A  differential  diagnosis  is  made  between  shock  and  syncope 
and  the  article  concludes  by  saying  that  in  fact  we  know  nothing  of  the 
pathological  anatomy  of  shock  or  of  its  pathogenesis.  The  entire  bibliography 
on  shock  is  so  meager  that  it  may  be  interesting  from  an  historical  stand  point. 
In  addition  to  those  already  maintained,  the  field  is  practically  covered  by 
the  following: 

Gross,  "System  of  Survey"  (1864). 

Erichsen,  "The  Railway  and  Other  Injuries  to  the    Nervous   System" 
(1866). 

Verneuil,  "de  la  mort  prompte  apres  certaines  blessures  ou  operations" 
(1869). 


384  THE  ABDOMINAL  AND  PELVIC  BRAIN 

Savory,  "Collapse,"  "Holmes  System  of  Surgery"  (1870). 

Fisher,  "In  Volkman  Samml,  klin.  Vortr. "  (1870). 

Demarquay,  "In  comptes  rendus  de  l'Academie  des  sciences"  (1871). 

Renard,  "Arch;  Gen.  demed."  (1872). 

Blum,  "Du  choc  traumatique  Arch,  gen  de  med. "  (1876). 

Le  Dentu,  "Bull  de  la  Soc.  de  chir. "  (1877). 

Vincent,  "Des  causes  de  la  mort  prompte  apres  les  grands  trauma  tismes 
accidentels  et  chirurgicaux  Thesis"  (1878). 

Piechaud,  "Que  doit  on  entendre  par  l'expression  de  choc  traumatique" 
(1880). 

Jondan  Furneaux,  on  "Shock  after  Surgical  Operations  and  Injuries," 
"British  Medical  Journal"  (1880). 

Raffer,  "La  Spermantate"  (1882). 

Torrier,  "choc  traumatique  Elements  de  path.  chir.  generale"  (1885). 

George  Friedlander,  "arch,  fur  klin.  chirurg."  (1903-4). 

Dennis,  "System  of  Surgery"  (1895). 

Mummery,  Second  Hunterian  lecture,  "New  York  Medical  Journal"  of 
April  15,  1905. 

^ETIOLOGY. 

From  clinical  observation  of  the  phenomena  of  shock,  a  rather  arbitrary 
division  of  the  aetiology  has  been  made,  viz.:  Predisposing  and  exciting 
causes.  To  establish  this  as  a  scientific  classification  much  more  must  be 
known  regarding  susceptibility  to  shock.  Infants  are  said  to  be  almost 
immune,  while  youth  is  considered  the  period  of  the  highest  susceptibility. 
Immunity  is  therefore  before  the  age  when  the  cerebrospinal  and  sympa- 
thetic systems  assume  their  reciprocal  positions  in  the  nervous  system,  sus- 
ceptibility from  the  time  when  the  untrained  cerebrospinal  system  assumes 
more  established  control  over  the  sympathetic  until  the  element  of  mental 
influence  comes  in  as  a  factor.  To  counterbalance  this  extreme  suscepti- 
bility of  youth  comes  in  the  fact  that  at  this  time  the  resisting  powers  are 
greater  and  many  cases  are  recorded  by  different  authors  of  recovering  from 
the  most  profound  shock  in  the  young  which  must  certainly  have  proved 
fatal  in  the  old.  It  would  almost  seem  that  the  proposition  could  be  laid 
down  that  the  power  to  withstand  and  overcome  shock  is  in  inverse  ratio  to 
the  susceptibility.  Dr.  Kicrnan  says  that  the  insane  are  not  susceptible  to 
the  influences  which  produce  shock  in  the  sane,  and  in  fact  the  effects  may 
be  directly  contrary — a  wide  field  for  study  and  speculation.  Certain  peoples 
are  said  to  be  practically  immune  and  others  to  be  little  affected.  Dr.  John 
H.  Packard  writes  interestingly  on  this  subject.  He  says  that  Hindoos  bear 
injuries  and  operations  impassively;  that  Negroes  are  not  easily  affected  and 
that  Americans  are  especially  susceptible  to  the  influences  of  shock.  It  has 
been  observed  that  injuries  inflicted  while  the  subject  is  under  the  influence 
of  intoxicating  liquors  rarely  produce  severe  shock.  If  all  these  clinical 
observations  can  be  substantiated  it  would  point  very  strongly  to  a  large 
mental  element  in  every  case  of  shock,  either  directly  or  indirectly.       When 


SHOCK  385 

all  is  said,  however,  the  real  factor  in  each  constitution  which  speaks  for  or 
against  susceptibility,  the  vital  force,  will  after  all  no  doubt  remain  the 
unknown  quantity.  As  regards  the  varying  degrees  of  susceptibility  in  the 
different  organs  of  the  body,  the  most  vascular  tissues  and  those  most  highly 
supplied  by  the  sympathetic  nerve  have  been  found  to  be  most  easily 
affected. 

In  the  present  light  of  our  knowledge  we  may  consider  as  predisposing 
causes  all  conditions  which  impair  the  nutrition  of  the  nervous  system  and 
consequently  the  circulation;  exhausting  diseases,  prolonged  physical  pain 
or  mental  strain,  insomnia,  melancholia,  in  fact,  everything  which  reduces 
vital  force.  Mummery  says  in  his  second  Hunterian  lecture  that  in  elderly 
patients  a  very  high  blood  pressure  is  generally  observed,  largely  accounted 
for  by  arteriosclerosis,  and  that  in  such  patients  a  relatively  slight  fall  in 
blood  pressure  may  produce  shock.  It  is  as  a  predisposing  cause  that  hemor- 
rhage plays  its  proper  role  through  the  secondary  physiological  phenomnea 
of  anaemia  which  leaves  the  ganglia  to  be  bathed  with  impoverished  blood  and 
as  a  surgical  condition  to  be  handled  surgically  should  be  sharply  differen- 
tiated from  shock  proper.  The  exciting  causes  of  shock  may  be  more  satis- 
factorily considered  under  the  classification  of  traumatic  and  mental.  Direct 
traumatism  of  the  tissues  may  result  from  accidental  injuries  or  from  trauma 
during  the  course  of  surgical  procedures.  Many  writers  treat  this  last  con- 
dition under  a  separate  classification  as  surgical  shock.  It  seems  true  that 
this  subject  can  be  treated  scientifically  only  as  a  subdivision  of  the  general 
classification  of  traumatism,  which  is  either  accidental  or  surgical.  The 
confusion  has  arisen  by  considering  hemorrhage  as  an  exciting  cause  of 
shock  instead  of  giving  it  its  proper  classification  as  a  surgical  complication 
and  secondly  by  the  involvement  of  the  anaesthesia  in  the  aetiology.  All  sur- 
gical writers  agree  that  the  frequency  of  shock  has  greatly  lessened  since  the 
general  use  of  anaesthesia  and  this  fact  speaks  loudly  against  operating  under 
partial  or  local  anaesthesia,  as  a  routine  practice.  I  have  seen  patients  pro- 
foundly influenced  by  an  excessive  quantity  of  the  anaesthetic,  either  on 
account  of  the  manner  in  which  it  was  administered  or  the  length  of  time 
the  patient  has  been  held  under  its  influence,  with  no  symptoms  of  shock 
whatever,  and  I  cannot  think  the  effects  of  long  anaesthesia,  serious  as  they 
are,  can  legitimately  be  considered  as  factors  in  the  production  of  shock. 
The  whole  story  of  a  depressed  nervous  system  following  a  prolonged  anaes- 
thesia is  told  in  the  added  traumatism  caused  by  the  repeated  and  unnecessary 
handling  of  the  tissues  and  the  exposure  to  atmospheric  influences  tissues 
normally  protected  by  the  coverings  of  fascia  and  skin.  During  extensive 
experimentations  in  intestinal  operations  on  dogs,  Dr.  Byron  Robinson 
demonstrated  that  the  shock  following  these  procedures  was  in  direct  propor- 
tion to  the  amount  of  manipulation  or  traction  in  the  abdominal  viscera  and 
duration  of  exposure;  that  is,  the  amount  of  trauma  inflicted  upon  the 
sympathetic  nerve.  Sudden  blows,  especially  in  the  region  of  the  solar 
plexus,  burns  and  scalds  involving  large  areas,  all  manner  of  traumatic 
injuries,  especially  those  producing  extensive   crushing  of    tissues,  are    the 


386  THE  ABDOMINAL  AND  PELVIC  BRAIN 

principal  exciting  causes  in  shock  from  accidental  traumatism.  It  has  been 
observed  that  burns  involving  a  large  area,  causing  extensive  nerve  periphery- 
trauma,  cause  more  profound  symptoms  than  deeper  burns  covering  a 
small  area.  Irritation  in  one  organ  may  produce  nerve  storms  in  a  distant 
one.  The  introduction  of  the  sound  in  the  uterus  or  the  catheter  in  the  male 
urethra  may  produce  faintness,  nausea  or  even  vomiting.  Dr.  Nicholas 
Senn  demonstrated  a  rare  case  in  his  clinic  which  well  illustrates  the  prin- 
ciple of  reflex  nervous  irritation.  The  patient  came  into  the  hospital  with  a 
history  of  anurea  for  sixty  hours.  The  right  kidney  was  enormously 
distended,  the  left  apparently  normal.  A  diagnosis  was  made  of  right 
ureteral  calculus,  which  was  removed.  During  the  period  of  convalescence 
both  kidneys  secreted  an  equal  amount  of  urine,  proving  conclusively  that 
the  suppression  of  urine  from  the  left  kidney  was  caused  by  the  reflex  irrita- 
tion produced  by  the  disturbance  in  the  right.  The  size  and  extent  of  the 
renal  ganglia  and  their  nearness  to  the  solar  plexus  give  to  the  kidneys  an 
especially  strong  sympathetic  connection.  From  the  first  observations  made 
in  the  subject  to  the  present  day,  all  writers  have  recognized  the  mental 
element  in  aetiology  of  the  phenomena  of  shock.  Davey,  1858,  cites  in  detail 
many  cases  and  says  the  part  played  by  the  mind  in  the  production  of 
"syncope"  is  not  sufficiently  appreciated.  Clinical  observation  has  estab- 
lished the  fact  that  a  profound  mental  impression  may  cause  all  the  nervous 
phenomena  following  a  blow  over  the  solar  plexus.  Sad  news,  fright,  violent 
emotions  may  be  followed  by  the  same  vasomotor  paralysis  with  all  its 
accompanying  nervous  manifestations;  and  when  this  is  said,  all  has  been 
said  regarding  our  knowledge  of  the  influence  of  the  mind  in  the  production 
of  the  phenomena  of  the  shock. 

PATHOLOGY. 

As  the  result  of  some  experimentation  and  much  speculation  two  theories 
regarding  the  pathology  of  shock  have  been  evolved,  viz. :  Vasomotor 
paresis  and  cardiac  paralysis.  Almost  all  of  the  modern  investigators  hold 
to  the  theory  of  vasomotor  paresis.  The  nervous  impression  is  conveyed  to 
the  medulla  by  the  afferent  nerves,  causing  vasomotor  paralysis  and  dilata- 
tion. There  is  a  more  or  less  rapid  fall  in  blood  pressure.  The  vessels  lose 
their  normal  tonicity  which  is  necessary  to  the  rapid  transition  of  the  blood, 
the  first  effect  is  contraction  in  the  caliber  of  the  capillaries,  followed  quickly 
by  dilatation,  with  at  first  increase  in  rapidity  of  the  blood  current,  but  in 
proportion  as  the  dilatation  increases  the  rapidity  decreases  and  may  proceed 
to  a  complete  stasis.  The  right  side  of  the  heart  becomes  engorged  and 
does  not  empty  at  each  contraction,  accumulating  largely  in  the  relaxed  veins, 
leaving  the  arteries  partially  emptied;  the  patient  bleeds  into  his  own  veins. 
The  blood  is  normal  into  the  abdominal  vessels.  Cerebral  anaemia  results  as 
a  natural  consequence  and  a  slowing  of  the  activity  of  all  the  different 
viscera  dependent  for  the  fulfillment  of  their  physiological  functions  upon  a 
perfect  blood  supply.  The  influence  on  the  heart  together  with  all  other 
viscera  is  therefore  secondary   to   the    paralysis   of   the   vasomotor  system 


SHOCK  387 

through  the  great  reorganizing  center,  the  solar  plexus,  the  abdominal  brain. 
The  phenomena  of  shock  are  therefore  the  result  of  a  reflex  inhibition  affect- 
ing all  the  functions  of  the  nervous  system,  causing  a  lowering  of  the  general 
blood  pressure,  checking  normal  metabolism,  arresting  the  exchanges 
between  blood  and  tissues;  the  venous  blood  becomes  red,  temperature 
lowers  in  consequence  of  the  lowered  blood  pressure,  respiration  slows  and 
we  have  a  picture  of  systematic  asphyxia.  The  entire  mechanism  of  life  is 
deranged,  the  balance  of  power  is  destroyed  and  each  organ  is  in  an  indepen- 
dent control  of  its  own  functions  for  the  time  being  and  consequently  only  as 
long  and  as  thoroughly  as  its  limited  reserve  force  will  allow.  Brown- 
Sequard,  Goltz  and  Savory  advanced  the  theory  of  cardiac  paralysis.  They 
gave  as  the  conclusion  of  all  their  experiments  that  shock  was  caused  by  a 
violent  impression  on  some  portion  of  the  nervous  system  acting  at  once 
through  a  nerve  center  upon  the  heart  and  destroying  its  action.  No  reliable 
findings  have  been  found  at  autopsy.  Parascandola  claims  to  have  found 
certain  changes  in  the  spinal  cord  after  profound  shock  affecting  the  cell 
body,  prolongations  nucleus  and  nucleolus,  constituting  chromatolysis,  frag- 
mentation, nuclear  and  perinuclear. 

It  must  be  admitted  that  the  pathology  of  shock  after  all  remains  very 
indefinite  and  unsatisfactory,  the  x,  as  Dr.  Senn  has  called  it  in  the  surgical 
formula.  It  is  therefore  very  difficult  to  give  a  comprehensive  definition  of 
this  ignis  fatuus  in  the  domain  of  pathology.  Based  in  reality  more  on  the 
phenomena  than  upon  the  pathology,  according  to  our  present  light  we  must 
consider  it  as  primarily  a  disturbance  of  the  great  sympathetic  nervous 
system  afflicting  secondarily  the  entire  vascular  system,  a  more  or  less 
profound  impression  on  the  sympathetic  nerve  producing  a  vasomotor  paresis 
with  a  consequent  dilatation  of  the  right  side  of  the  heart  and  the  large 
vessels,  especially  the  abdominal,  and  in  consequence  lowering  the  general 
blood  pressure  and  deranging  through  the  solar  plexus  all  the  automatic 
visceral  ganglia,  and  consequently  destroying  their  functional  activity, 
rhythm,  absorption  and  secretion. 

SYMPTOMS. 

The  phenomena  of  shock  manifest  themselves  through  the  tripod  of  vital 
forces,  the  nervous,  circulatory  and  respiratory  systems,  and  principally  in 
those  organs  most  highly  supplied  by  the  sympathetic  system.  The  rhythm 
of  the  viscera  is  disturbed,  secretions  are  diminished,  causing  an  intense 
thirst,  the  cry  of  the  tissues  for  fluids;  there  is  a  general  trophic  disturbance; 
the  heart  action  and  the  respirations  are  increased,  the  temperature  is  sub- 
normal, the  face  is  pale,  the  lips  are  blue,  the  pupils  dilated;  there  is  nausea, 
vomiting  and  restlessness,  more  or  less  pronounced  according  to  the  degree 
of  shock,  until  the  stage  of  collapse,  when  the  reflexes  are  lost.  A  cold, 
clammy  sweat  appears  on  the  entire  surface  of  the  body,  and  the  extremities 
are  cold.  Shallow  respirations,  with  frequent  sighing,  yawning,  hiccoughs 
are  often  added  to  the  clinical  picture. 

In  the  most  profound  shock,  where  the  cerebrospinal  system  is  involved, 


388  THE  ABDOMINAL  AND  PELVIC  BRAIN 

this  picture  may  be  changed  by  the  substitution  for  the  phenomena  caused 
by  a  hyperirritation  of  the  sympathetic  system  as  nausea,  vomiting  and  rest- 
lessness, those  manifestations  resulting  from  a  secondary  depression  of  the 
cerebrospinal  system  causing  a  loss  of  reflexes,  as  involuntary  urination  and 
bowel  movements;  delirium  and  even  stupor  may  appear.  The  cold  sweat, 
rapid,  irregular  pulse,  subnormal  temperature  here  persist  in  a  more  pro- 
found degree,  some  observers  having  noted  a  fall  in  temperature  of  6°  F. 
During  the  War  of  the  Commune  observations  were  taken  in  regard  to  the 
temperature  after  injuries.  The  average  temperature  varied  from  96.5°  to 
97.5°,  the  lowest  registering  at  93.5°.  The  fall  was  greater  after  shell 
wounds  and  the  curious  fact  was  noted  that  there  was  a  uniform  lower  tem- 
perature among  the  insurgents  than  among  the  regular  troops. 

Authenticated  cases  have  been  reported  where  jaundice,  deafness  and 
arrest  of  lacteal  and  menstrual  secretions  have  followed  profound  shock. 
Many  efforts  have  been  made  to  classify  the  nervous  symptoms  of  shock, 
but  all  are  unsatisfactory  for  the  reason  that  one  state  runs  so  insensibly  into 
another  that  it  is  impossible  to  measure  the  degree,  except  by  the  rate  of 
recovery,  and  here  again  come  in  the  unsolved  problems  of  susceptibility 
and  resistance  and  we  simply  travel  in  a  circle  and  soon  find  ourselves  at  the 
starting  place  again.  The  only  classification  which  is  any  aid  in  diagnosis 
and  prognosis  is  a  differentiation  between  the  state  implicating  only  the 
functional  activity  of  the  sympathetic  system  and  that  in  which  the  cerebro- 
spinal is  also  involved  and  even  here  the  symptoms  run  so  imperceptibly  into 
each  other  that  classification  is  elusive;  even  in  collapse  consciousness  may 
be  retained  until  death. 

The  intensity  of  physical  shock  is  influenced  by  four  principal  considera- 
tions: the  extent  of  the  injury,  that  is,  the  number  of  nerve  peripheries 
involved;  the  nearness  of  the  traumatism  to  the  solar  plexus;  the  character 
of  the  injury,  the  more  crushing  or  bruising  of  the  nerves  the  greater  being 
the  nervous  impression ;  and  the  severity  of  the  pain  produced.  It  is  there- 
fore from  the  standpoint  of  intensity  rather  than  by  means  of  a  scientific 
classification  that  we  must  study  the  phenomena  of  shock. 

DIAGNOSIS. 

The  diagnosis  of  shock  is  simply  the  recognition  of  the  clinical  phenom- 
ena as  here  we  have  no  pathological  findings  to  aid  us.  The  clinical  man- 
ifestations of  this  nerve  storm  are  however  so  pronounced  that  prac- 
tically the  only  difficulty  lies  in  differentiating  this  condition  from  syncope 
caused  by  severe  hemorrhage,  with  which  there  is  danger  of  confounding 
it.  When  syncope  co-exists  with  shock  it  is  often  extremely  difficult  to 
establish  the  presence  of  internal  hemorrhage  as  a  complication.  In  one 
condition  the  blood  leaves  the  peripheries  and  congests  the  abdominal  vessels, 
in  the  other  the  large  and  small  vessels  are  equally  deprived  of  the  usual 
volume  of  blood.  In  nervous  shock  certain  tissues  only  lose  their  blood 
supply,  while  there  is  no  diminution  in  the  quantity  of  blood.  In  the  one 
the  primary  violence  is  to  the  nervous  system,  in  the  other  the  circulatory 


SHOCK  389 

system  is  attacked  directly.  Syncope  causing  always  a  cerebral  anaemia  is 
practically  identical  with  the  last  manifestations  of  overwhelming  shock,  or 
collapse.  As  a  recognition  of  the  presence  of  hemorrhage  is  often  of  the 
utmost  importance,  sometimes  meaning  even  the  saving  of  a  life,  we  should 
never  rest  content  with  a  diagnosis  of  shock  until  we  have  excluded  the 
possibility  of  hemorrhage  by  every  means  in  our  power.  If  the  patient  is 
seen  immediately  after  the  injury,  or  in  surgical  cases  where  internal  hemor- 
rhage may  arise,  the  most  reliable  source  for  establishing  a  differential 
diagnosis  is  by  observation  of  the  pulse  and  temperature.  Both  conditions, 
to  be  sure,  produce  a  rapid  pulse  with  normal  or  subnormal  temperature,  but 
there  is  a  decided  difference  in  the  course  of  the  pulse  and  temperature 
which  with  careful  observation  one  can  not  fail  to  recognize.  In  internal 
hemorrhage  there  is  a  gradually  rising  pulse,  more  or  less  rapid  according  to 
the  rapidity  of  the  bleeding,  with  a  gradual  lowering  of  temperature,  the 
golden  rule  in  abdominal  surgery  establishing  the  presence  of  internal 
hemorrhage  laid  down  by  Mr.  Lawson  Tait  over  twenty  years  ago.  In 
shock  proper,  however,  we  have  the  maximum  rapidity  of  pulse  and  depres- 
sion of  temperature  at  the  time  of  infliction  of  the  trauma  and  co-existent 
with  all  other  clinical  manifestations,  as  the  rapid  shallow  breathing,  cold 
sweat,  and  dilated  pupils. 

To  illustrate :  A  patient  is  taken  from  the  operating  table  with  a  tem- 
perature of  99°-100°,  rectal,  pulse  90-100.  In  a  half  hour  the  pulse  is  110-120, 
the  temperature  is  found  to  be  98°;  in  another  fifteen  minutes  to  half  an 
hour  the  pulse  has  risen  to  130-140  and  the  temperature  is  falling  towards  97° 
and  the  diagnosis  of  internal  hemorrhage  is  practically  established.  This 
rising  of  the  pulse  with  a  corresponding  depression  of  temperature  may  be 
extremely  gradual  and  extend  over  hours  and  even  days  in  cases  of  slow 
bleeding,  sometimes  a  mere  oozing,  as  where  an  hematoma  or  an  hema- 
tocele is  forming  and  before  the  period  of  infection  or  localized  peritonitis, 
and  here  of  course  the  diagnosis  is  more  obscure,  but  fortunately  less  urgent. 
If,  however,  the  patient  is  taken  from  the  table  with  a  pulse  of  120-140  or 
upwards,  rectal  temperatures  98°-97°,  respirations  30-40,  and  even  if  these 
conditions  persist  for  several  hours,  we  have  no  reason  to  fear  internal 
hemorrhage,  and  if  after  the  first  half  hour  of  the  patient's  rest  in  bed  the 
pulse  and  respiration  slow  ever  so  little  and  the  temperature  rise  even  a 
fraction  of  a  degree  we  may  know  that  we  have  to  deal  with  a  case  of 
recovering  shock.  The  surgical  nurse  should  be  taught  to  make  this  differ- 
ential diagnosis  through  a  clinical  study  of  pulse  and  temperature  and 
respiration,  as  it  is  to  her  that  we  must  look  for  the  accurate  observation  and 
a  prompt  report  of  a  condition  in  which  minutes  count  in  the  saving  of  a  life. 

PROGNOSIS. 

We  have  little  to  guide  us  in  forming  a  prognosis,  as  here  again  the 
unknown  quantity,  the  vital  force  of  the  individual,  the  power  of  resistance 
of  the  tissues  to  the  nervous  impression  comes  in  as  the  most  important 
factor  in  the  equation.     In  general  the  temperature  is  the  best  guide  here 


390  THE  ABDOMINAL   AND   PELVIC  BRAIN 

also.  A  persistence  of  96°  or  below  for  several  hours  warrants  an  unfavor- 
able prognosis  while  even  a  slight  rise  from  time  to  time  may  be  taken  as  a 
happy  omen. 

TREATMENT. 

The  many  and  diverse  theories  regarding  the  treatment  of  shock  shows 
conclusively  the  chaotic  state  of  the  professional  mind  regarding  this  con- 
dition. One  writer  is  so  confused  in  his  interpretation  of  the  phenomena 
?that  he  advised  at  the  same  time  morphine,  strychnia,  digitalis,  nitrogly- 
cerine, whisky  and  citrate  of  caffeine.  No  one  has  done  more  to  bring  order 
out  of  this  chaos  than  Dr.  Geo.  C.  Crile,  of  Cleveland,  by  his  experiments  on 
dogs.  He  has  practically  demonstrated  not  only  the  uselessness  but  the  harm- 
fulness  of  strychnia  in  shock  and  that  the  rational  treatment  lies  in  raising  the 
blood  pressure.  He  lays  down  the  principle  that  the  treatment  must  be 
sedative  to  the  sympathetic  system  and  relaxing  to  the  arterioles.  To  this 
end  he  advises  compression  of  the  abdomen  and  extremities  to  prevent  the 
accumulation  of  blood  in  the  large  veins,  with  the  administration  of 
adrenalin  given  with  salt  solution.  Dr.  Halsted  advises  morphine  also 
normal  salt.  It  is  interesting  to  note  that  Morris,  as  early  as  1868,  advised 
opium  1-2  gr.  every  two  hours. 

Rest  and  heat,  preferably  moist,  added  to  these  remedial  agents,  and  we 
have  certainly  fulfilled  the  requirements  for  treatment  in  accordance  with 
all  that  is  known  of  the  pathology  of  shock,  to  quiet  the  nervous  system  and 
relax  the  arterioles.  The  addition  of  strychnine,  digitalis,  nitroglycerine  and 
whisky  is  certainly  irrational.  The  heart  is  already  overworked  by  nature's 
effort  to  repair  the  damage  and  strychnine  may  prove  to  be  what  the  whip 
is  to  the  spirited  horse  at  the  end  of  the  race,  and  under  its  influence  the 
heart  may  exhaust  itself  in  a  last  effort.  When  there  has  been  hemorrhage  as 
a  complication  the  first  indication  is  most  assuredly  to  restore  the  volume  of 
blood,  but  it  is  certainly  irrational  to  increase  the  quantity  of  blood  suddenly 
when  the  normal  amount  is  present  in  the  vascular  system  and  the  difficulty 
lies  in  reality  in  properly  caring  for  the  usual  quantity.  It  would  seem 
theoretically  that  increasing  the  volume  of  blood  rapidly  under  these 
conditions  would  only  increase  the  local  congestion  in  the  large  blood  vessels 
and  make  the  ultimate  restoration  of  the  normal  blood  pressure  more 
difficult.  Small  quantities  of  hot  water  per  mouth  or  rectum  sufficient  to 
allay  the  thirst,  or  the  slow,  continuous  rectal  irrigation,  which  introduces 
the  fluid  gradually  and  as  the  tissues  are  prepared  to  appropriate  it  seems  to 
me  to  be  more  rational  than  intravenous  infusion  of  a  large  quantity  of  fluid. 
Briefly  stated,  the  treatment  in  hemorrhage  is  to  restore  immediately  the 
normal  volume  of  blood,  in  shock  to  restore  the  normal  blood  pressure. 
Dr.  Robert  Dawbarn  calls  attention  to  the  danger  of  using  plain  water  in  intra- 
venous infusion  in  hemorrhage  and  says  that  experiments  on  dogs  have 
proven  that  it  will  kill  almost  as  quickly  as  prussic  acid.  He  advises  normal 
salt  solution  at  a  temperature  of  118°-120°  F.,  one  to  two  quarts,  ten  minutes 
to  be  taken  in  introducing  it.  If  the  kidneys  are  not  functionating  normally, 
the  quantity  must  be    lessened. 


SHOCK  391 

Some  writers  make  a  point  on  the  value  of  force  of  gravity  and  advise 
lowering  of  the  head.  Mummery  says  that  the  ideal  treatment  of  shock 
would  be  the  raising  of  the  external  air  pressure,  and  thus  substituting  an 
artificial  peripheral  resistance  for  the  lost  peripheral  resistance  caused  by 
the  exhaustion  of  the  vasomotor  centers,  but  that  as  yet  this  method  is  not 
practical. 

The  administration  of  foods  and  drugs  by  the  stomach  is  distinctly 
counterindicated.  The  same  principle  holds  good  here  as  in  the  case  of  the 
heart.  The  stomach  is  exhausted  and  oversensitive  and  should  not  be 
irritated  or  stimulated  to  work  until  the  period  of  exhaustion  has  passed. 
Perhaps  the  principal  factor  in  the  therapeutics  of  shock  is  rest,  anatomic 
and  physiologic  rest.  This  of  course  forbids  all  stimulants,  alcoholic  as  well 
as  stimulating  drugs.  Light  and  sound  should  be  excluded  that  the  tired 
brain  may  share  in  the  general  calm  with  which  we  seek  to  surround  our 
patient. 

PREVENTION. 

The  preventive  treatment  of  shock  lies  almost  entirely  in  the  domain  of 
surgery.  Here  is  indeed  the  ounce  of  prevention  worth  a  pound  of  cure. 
Paget  in  1868  advised  hypodermics  of  morphine  after  operations  before  the 
patient  is  restored  to  consciousness  to  lessen  the  shock  caused  by  pain. 
Davey  in  1858  recommended  waiting  in  cases  of  shock  injuries  not  compli- 
cated with  hemorrhage  until  some  of  the  "Promethian  fire"  had  returned  to 
the  shocked  tissues.  Dr.  Harvey  Cushing  and  Dr.  Crile  advise  the  cocainiza- 
tion  of  main  nerve  trunks  thus  "blocking"  the  nerves  proximal  to  the  site  of 
operation,  in  severe  cases  where  shock  may  be  anticipated.  Dr.  Crile  has 
invented  a  pneumatic  rubber  suit  with  which  he  envelops  the  patient,  which 
he  claims  assists  greatly  in  preserving  the  normal  blood  pressure.  There  is 
no  doubt  that  much  can  be  done  by  the  proper  preparation  of  the  patient 
before  coming  to  the  operating  table  to  prevent  subsequent  shock  and  the 
practice  of  some  surgeons  of  rushing  nonemergency  cases  under  the  knife 
without  any  preparatory  treatment  cannot  be  too  strongly  condemned.  It  is 
self-evident  that  the  more  normal  the  condition  of  the  system  the  greater 
will  be  the  resistance  of  shock.  The  indication,  then,  is  to  bring  all  organs  as 
far  as  possible  to  their  highest  function.  This  is  especially  important  in  the 
case  of  the  kidneys,  bowels  and  skin,  the  great  eliminatory  organs;  these  must 
actually  secrete  normally  at  the  time  of  operation  if  we  are  to  expect  normal 
conditions  to  follow.  Free  drainage  by  means  of  nature's  own  remedy,  water 
used  liberally,  internally  and  externally,  for  several  days  previous  to  operation, 
will  in  ordinary  cases  be  sufficient  to  put  the  kidneys  and  skin  in  good  condition. 
A  free  cathaisis,  making  sure  that  the  entire  intestinal  tract  is  cleared,  is  of 
the  utmost  importance.  The  liberal  use  of  a  normal  salt  solution  as  long 
before  the  operation  as  possible  not  only  aids  in  the  systemic  drainage  but 
increases  the  volume  of  the  blood  and  promotes  the  rapid  metabolism  which 
is  so  important  in  preserving  the  quality  of  the  flood.  The  stomach  should 
be  absolutely  empty  when  the  patient  is  brought  to  the  operating  table,  as  it 


392  THE  ABDOMINAL  AND  PELVIC  BRAIN 

is  one  of  the  first  viscera  to  manifest  reflex  irritation,  and  a  persistent  nausea 
and  vomiting  keeps  the  patient  in  constant  distress  and  the  muscular  system 
in  action,  preventing  the  rest  and  relaxation  so  necessary  to  recovery. 

Rapid  operating,  as  rapid  as  is  consistent  with  a  proper  attention  to  detail, 
is  unquestionably  one  of  the  greatest  factors  in  the  prevention  of  surgical  shock. 
The  entire  regime  of  the  operating  room  should  be  conducive  to  this  end. 
Every  detail,  should  be  attended  to  as  far  as  possible  before  the  patient  is 
placed  under  the  anaesthetic.  Minutes  wasted  for  any  reason  while  the 
patient  is  under  abnormal  conditions  is  an  injustice  to  all  concerned.  In 
abdominal  surgery  involving  the  peritoneal  cavity  there  is  little  doubt  that 
shock  is  in  almost  direct  proportion  to  the  amount  of  handling  and  exposure 
of  the  intestines.  Mummery  says  that  turning  the  intestines  out  of  the 
abdomen  is  always  followed  by  a  sudden  and  dangerous  fall  of  blood  pressure. 
Methods  of  operating,  therefore,  in  which  these  viscera  are  little  or  not  at  all 
exposed  can  certainly  claim  to  be  a  factor  in  the  preventive  treatment  of  shock. 
I  have  frequently  seen  patients  put  to  bed  after  the  removal  of  large  myomata 
(hysterectomy)  per  vaginam  with  no  more  symptoms  of  shock  than  after  a 
normal  labor.  The  choice  of  anaesthetic  in  cases  where  shock  is  apprehended 
is  considered  by  some  of  great  importance.  Mummery  says  that  ether  anaes- 
thesia almost  always  causes  a  rise  in  blood  pressure,  while  chloroform  is 
usually  accompanied  by  a  fall  in  blood  pressure,  and  believes  the  chloro- 
form-ether mixture  to  be  the  best  anaesthetic  from  the  point  of  view  of 
subsequent  shock.  It  would  seem,  however,  that  there  are  more  important 
points  to  be  considered  in  the  choice  of  an  anaesthetic,  as  the  organic 
condition  of  the  heart,  kidneys  and  lungs,  as  we  have  more  definite  know- 
ledge of  the  action  of  ether  and  chloroform  on  these  organs.  The  tempera- 
ture of  the  operating  room  is  of  great  importance,  and  should  be  kept  between 
80°  and  85°F.  Wetting  and  chilling  of  the  body  should  be  avoided,  and  heat 
applied  directly  by  means  of  a  water  cushion  placed  over  the  operating  table 
assists  greatly  in  preserving  the  normal  body  temperature.  The  mental 
state  in  which  the  patient  comes  to  the  operating  table  is  no  doubt  an 
important  factor.  Every  effort  should  be  made,  therefore,  to  inspire  the 
patient  with  confidence  in  the  success  of  the  operation,  that  the  demon  of 
fear  may  be  exorcised  from  the  sick  room,  that  the  spirit  of  hope  may  hover 
around  the  last  few  conscious  breaths  and  be  the  first  to  greet  the  awakening 
mind  struggling  back  to  consciousness. 


CHAPTER   XXXI. 

SUDDEN  ABDOMINAL  PAIN— ITS  SIGNIFICANCE. 

"Give  me  liberty  or  give  me  death." — Patrick  Henry,  American.  (1136-1199.) 
Truth  should  he  constantly  advocated  because  the  majority   constantly  advocate  error. 

Abdominal  surgery  is  no  longer  a  pioneer  work.  It  is  the  result  of  the 
accumulated  experience  of  the  past  fifty  years.  Its  success  is  based  on  well 
tried  practices.  It  is  a  jealous  field,  filled  with  battles  lost  and  won,  marked 
here  and  there  with  sad  regrets,  chagrin  from  unavoidable  mistakes,  however 
often  brightened  by  the  light  of  success.  A  master-hand  in  abdominal 
surgery  is  a  hard-earned  reputation.  However,  accumulative  experience  of 
fifty  years  has  still  left  obscure  points  in  abdominal  surgery  which  the  genius 
of  Lawson  Tait  has  attempted  to  set  at  rest  by  the  exploratory  and  confirma- 
tory incision — a  misused  and  abused  field. 

During  the  past  fifteen  years  I  have  been  specially  interested  in 
gynecology  and  abdominal  surgery,  and  during  these  years  has  risen  the 
question  of  abdominal  pain  and  its  signification.  To  interpret  abdominal 
pain  requires  the  best  skill  of  the  finest  head. 

Sudden,  severe  abdominal  pain  is  the  one  significant  early  symptom 
sounding  the  hope  for  relief  or  the  knell  of  doom.  In  the  interpretation  of 
sudden  appearance  of  abdominal  pain  lies  the  physician's  chance  of  success 
or  failure — usefulness  or  disaster.  This  cry  of  sudden  pain  may  come  from 
multiple  lesions  or  sources — it  may  be  the  appeal  of  a  strangulated  loop  of 
intestine  on  the  verge  of  gangrene;  the  demand  of  an  agonizing  ureter 
afflicted  with  a  bristling  calculus;  the  disaster  of  a  perforated  appendix  in 
the  dangerous  peritonitic  enteronic  area;  the  horrible,  grinding,  hopeless  pain 
of  a  biliary  calculus;  the  calamity  of  a  ruptured  gestating  oviduct;  or  from 
the  beginning  painful  perforative  peritonitis  of  impossible  diagnostic  origin — 
accompanied  by  excruciating  pain. 

Abdominal  pain  belongs  to  the  domain  of  the  nervus  vasomotorius,  the 
sympathetic  nerve,  and  should  be  interpreted  according  to  its  life  and  habits, 
in  relation  to  its  anatomy,  distribution  to  viscera  and  physiology  (rhythm) 
peristalsis.     Rhythm  is  a  physical  accompaniment  of  life. 

Severe  abdominal  pain  is  the  appeal  for  prompt,  efficient  assistance.  In 
the  first  place,  in  my  experience,  the  natural  manifestation  of  sudden  abdom- 
inal pain  is  too  frequently  obtunded,  dulled,  lulled  into  a  treacherous  quietude 
by  the  general  practitioner's  employment  of  large  hypodermic  injections  of 
morphia,  which  obscures  diagnosis.  Frequently  it  is  the  mode  of  onset,  the 
sudden  appearance  and  localization  of  the  pain  that  affords  the  sharpest  aid 
to  diagnosis,  and  if  the  sharpest,  delicate  symptoms  are  obscured  by  morphia 
it  may  jeopardize  the  patient's  life. 

393 


394 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


Sudden  pain  in  the  abdomen  is  frequently  the  guiding,  suggestive  means 
to  a  diagnosis.  Pain  in  any  location  is  the  conscious  expression  of  nerve 
trauma,  whether  it  be  macroscopic  or  microscopic. 

Pain  is  an  objective  as  well  as  a  subjective  symptom.  Its  subjective 
character  forces  us  to  depend  on  the  patient's  statement  for  its  location, 
severity,  duration.  Pain  is  the  most  constant  beginning  feature  and  frequently 
the  most  constant,  persistent  characteristic.  For  this  reason  the  practitioner 
should  secure  a  complete  clinical  history,  mode  of  onset,   location  of  pain, 

rhythmic  or  constant,  be- 
fore he  obscures  its  most 
delicate  and  valuable  aid 
to  diagnosis  by  narcotics. 
Abdominal  pain  is 
Nature's  warning  that 
mischief  is  afoot  in  the 
abdominal  viscera,  and  its 
manifestations  should  not 
be  obscured  by  opium  until 
sufficient  evidence  is 
secured  to  diagnose  the 
cause.  The  successful  di- 
agnosis depends  on  the 
most  careful  analysis  of 
every  available  symptom 
in  severe  abdominal  pain, 
which  is  defective  in  a 
narcotized  patient. 

A     characteristic     of 

sudden  abdominal  pain  is 

that  at  first  it  is  diffuse  or 

mainly   in   the    umbilical 

region  (the  abdominal 

brain,    the    sensorium    of 

the  abdominal  viscera). 

Gradually,    with    the 

lapse  of  time — hours — it  becomes  more  and  more  localized  in  the  region  of 

the  affected  organ  (beginning  local  peritonitis). 

A  suggestive  symptom  is  that  almost  all  patients  with  sudden  abdominal 
pain  especially  beginning  peritonitis,  vomit.  The  failure  of  the  general 
practitioner  in  appreciating  the  significance  of  sudden  severe  abdominal  pain 
results  in  late,  and  too  frequently  disastrous,  surgery,  also  in  disastrous 
treatment  by  administrating  cathartics,  the  enemy  of  visceral  quietude. 

In  sudden  abdominal  pain  the  pulse  in  general  is  of  more  practical  value 
than  temperature.  In  some  advanced,  grave  abdominal  diseases  the  pain  is 
limited  or  absent.  Overwhelming  profound  sepsis  has  obtunded  sensibility. 
In  sudden  abdominal  pain  the  first  and  foremost  matter  is  its  diagnosis — the 


STRANGULATION    OF   THE    SIGMOID    BY    BAND 

ORIGINATING    FROM   BILATERAL 

PYOSALPINX 

Fig.  85.  This  is  an  illustration  of  a  peritoneal  band 
obstructing  the  sigmoid  from  a  woman  physician  oper- 
ated by  Dr.  Lucy  Waite.  I  assisted  Dr.  Waite  and  saw 
the  elongated  band  attenuated  in  the  middle.  Its  rupture 
allowed  the  gas  to  rush  through  the  sigmoid  with  recovery. 
The  termination  of  the  band  (1)  is  at  2  and  4  on  the  right 
side  and  at  3  on  the  left  side. 


SUDDEN    ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


395 


rock  and  base  of  rational  treatment.     The  diagnosis  is  absolutely  required 
in  order  to  attempt  rationally  to  remove  the  cause. 

Probability  is  the  rule  of  life  and  it  is  just  as  applicable  in  diagnosing 
sudden  abdominal  pain  as  in  other  matters.  For  example,  when  a  man  is  at- 
tacked by  sudden  abdominal  pain  and  vomiting  with  rise  of  temperature, 
pulse  and  respiration,  the  probability  is  that  it  is  appendicitis — not  perfora- 
tion of  the  gastrium,  enteron  or  colon,  for  that  occurs  perhaps  one  hundred 
itimes  less  than  perforation  of  the 
appendix. 

Observation. — I  was  called  to 
attend  a  physician  who  was  at- 
tacked with  sudden  abdominal 
pain  while  riding  in  his  buggy. 
The  abdominal  pain  from  the 
beginning  was  located  several 
inches  to  the  left  of  the  medium 
line  of  the  abdomen.  The  diag- 
nosis was  ruptured  appendicitis 
from  a  potential  appendix,  i.  e., 
one  with  an  elongated  meso-cceco- 
appendicular  apparatus  capable 
of  extending  or  moving  to  loca- 
tions distant  from  the  usual  ap- 
pendicular site.  The  improbable 
diagnosis  was  intestinal  perfora- 
tion, because  the  appendix  per 
forates  perhaps  a  hundredfold 
more  than  the  intestine.  In  op- 
erating on  the  physician  forty 
hours  subsequent  to  the  attack  I 
found  the  peritonitis  localized  to 
the  left  of  the  medium  line  of  the 
abdomen  in  the  enteronic  coils 
located  in  the  left  iliac  fossa. 
The  potential  appendix  was 
during  operation  practically  in  its  usual  location,  however,  surrounded 
by  peritonitis.  The  explanation  was  evident.  He  had  a  potential  appendix, 
which  while  wandering  amongst  the  intestinal  loops  in  the  left  half  of  the 
abdomen  had  become  perforated  and  immediately,  before  adhesions  formed, 
returned  to  its  usual  location  in  the  right  iliac  fossa.  The  extensive,  varying 
mobility  of  the  cecum  and  appendix  should  be  included  in  the  anatomic 
diagnosis. 

Anatomy    is   the    solid    ground  of  nature  on  which  to  build  a  rational 
diagnosis  of  sudden  abdominal  pain. 


HERNIA  OF  8  FEET  OF  ENTERON  IN 
FOSSA  DUODENO-JEJUNALIS 

Fig.  86.  This  occurred  in  a  woman  about  35 
years  of  age.  The  8  feet  of  enteronic  loops  lying 
in  the  fossa  duodeno-jejunalis  were  reduced  with 
facility. 


396  THE  ABDOMINAL  AND  PELVIC  BRAIN 

patient's  history. 

We  should  study  the  history  of  the  abdominal  pain  in  each  patient  for 
aid  in  diagnosis. 

A  clinical  study  of  abdominal  pain  is  of  the  utmost  importance  to  both 
general  physician  and  abdominal  surgeon.  Has  the  patient  experienced 
similar  sudden  abdominal  pain  previously?  What  was  the  length  of  time 
elapsed  between  the  previous  attacks  of  pain?  If  the  pain  is  recurrent  it  is 
probably  from  the  same  original  cause,  e.  g.„  repeated  perforated  appendi- 
citis or  repeated  attacks  from  calculus  Has  the  pain  any  regular  persistent 
relation  to  the  ingestion  of  food  or  fluid?  If  so  we  examine  the  proximal 
end  of  the  tractus  intestinalis,  as  for  gastritis,  ulceration,  biliary  passages, 
pancreatic  disease  and  perhaps  appendicitis.  If  the  pain  persistently 
precedes  or  follows  defecation,  search  for  rectal  disease — hemorrhoids,  fissure, 
ulceration,  carcinoma.  If  the  pain  recurs  with  menstruation,  one  examines 
the  genitals.  If  the  pain  be  sudden  and  occurring  for  the  first  time,  we  should 
scrutinize  its  history  and  every  visceral  function.  Pain  following  extra 
exertion  may  be  due  to  hernial  strangulation,  ruptured  pregnant  oviduct, 
breaking  of  peritoneal  adhesions,  formation  of  volvulus,  rupture  of  a  cystic 
tumor,  an  ovarian  cyst,  or  other  tumor  or  viscus,  rotated  on  its  pedicle. 
Pain  following  extra  trauma  may  be  ruptured  bladder,  stomach,  intestines  or 
other  viscera.  In  gestation  an  impending  miscarriage  may  cause  sudden 
abdominal  pain.  Clinical  history  is  the  most  valuable  in  acute  abdominal 
pain — not  in  chronic.  Repeated  rough  rides  with  repeated  abdominal  pain  is 
suggestive  of  calculus.  The  repeated  abdominal  pains  due  to  painful  per- 
istalsis in  inflamed  ducts — biliary,  ureteral,  intestinal,  genital — is  still  difficult 
to  diagnose. 

It  should  be  distinctly  remembered  that  sudden  recurrent  abdominal 
pain  following  peritonotomy  or  peritonitis  is  mainly  due  to  peritoneal  bands 
checking  peristalsis,  or  painful  peristalsis  from  inflamed  viscera.  Sudden 
abdominal  pain  in  a  patient  who  had  had  hernia  is  liable  to  be  from  con- 
strictions of  peritoneal  bands.  The  clinical  history  is  frequently  a  pencil  of 
light  in  the  diagnosis  of  sudden  abdominal  pain. 

AGE   AND  SEX. 

Age  and  sex  are  of  extreme  value  in  diagnosing  sudden  abdominal  pain. 
In  woman,  in  the  maximum  sexual  phase,  the  lesions  of  the  tractus  genitalis 
surpass  those  of  the  tractus  intestinalis.  Still  a  differential  diagnosis  between 
appendicitis  and  right-sided  inflamed  oviduct,  peritoneum  and  ovary,  is 
frequently  difficult. 

Sudden  pain  in  anemic  young  women  may  be  perforating  round  ulcer  of 
stomach. 

In  children  lesions  of  the  tractus  intestinalis  preponderate,  gastero- 
enteritis,  invagination,  enterocolitis,  appendicitis. 

In  senescence  malignancy  may  attack  the  gastrum,  colon,  rectum,  gall 
bladder  and  pancreas,  as  well  as  ulceration  of  the  intestinal  tract  usher  in 
pain. 


SUDDEN   ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


397 


CHARACTER    OF   ABDOMINAL   PAIN. 

Abdominal  pain  may  be  acute  or  chronic,  it  may  be  tolerant  or  excruciat- 
ing (peritoneal  extravasation).  It  may  be  due  to  intra-abdominal  or  extra- 
abdominal  disease.  It  may  arise  from  violent  peristalsis  (colic)  in  tubular 
viscera  or  from  inflammation.  Abdominal  pain  may  be  due  to  disease  or 
trauma. 

If  one  will  closely  watch  the  sudden  acute  abdominal  pain,  it  will  be 
quite  apparent  that  the  character  of  the  pain  in  most  of  the  acute  affections 
is  very  similar.  We  only  observe  a  reality  in  difference  of  degree  of  pain 
from  the  bearable  to  the  agonizing.  In  perforation  the  character  of  the 
pain  is  the  same  in  all  viscera.  In  invagination  it  is  paroxysmal  and  periodic, 
at  least  at  first,  due  to  irregular  and  violent  peristalsis.     In  internal  strang- 


HERNIA  IN  FOSSA  DUODENO-JEJUNALIS 

Fig.  87.  I  secured  this  specimen  from  an  autopsy.  The  subject  had  numerous  recur- 
rences as  was  demonstrated  by  the  marked  cicatricial  strictures  at  various  points  of  the 
enteron.     Also  saccular  dilatations  (9)  of  the  enteron  demonstrated  repeated  recurrences. 

ulation  it  is  generally  intense  and  periodic,  due  to  violent  peristalsis;  later 
continuous  and  of  an  aching,  dragging  character,  due  to  paralysis  of  the 
intestinal  segments.  In  appendicitis  the  pain  is  nearly  always  sudden  and 
intense,  i.  e.,  the  perforative  variety.  The  variety  of  appendicitis  with 
slowly  increasing  pain  is  likely  lymphatic  in  invasion  and  not  dangerous, 
simply  medical,  though  of  course  the  appendicular  mucosa  may  be  perforated. 
Sudden,  acute  abdominal  pain  of  a  lancinating  character,  and  quite  continu- 
ous, is  very  likely  to  be  due  to  perforation  of  the  appendix  or  digestive  tube, 
and  the  continuous,  agonizing  character  of  the  pain  is  a  heraldic  symptom 
of  diffuse  peritonitis— the  knell  of  life.  It  may  be  remembered  that  the 
character  of  sudden  acute  abdominal  pain  will  depend  on  the  capacity  of 
any  viscus  for  peristalsis,  i.  e.,  its  capacity  to  cause  colic  by  violent,   wild, 


398 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


irregular  muscular  action.  In  peristalsis  periodicity  must  not  be  forgotten, 
and  the  etiology  which  gives  rise  to  the  initation,  inducing  the  peristalsis.  It 
may  be  transitory  in  character,  as  food  irritation,  rapidly  forming  and  inducing 
invagination,  or  a  calculus  attempting  to  enter  a  duct.  Or  the  pain  may  be 
continuously  periodic,  as  a  calculus  lodged  in  some  canal,  appendix,  ureter, 
enteron,  colon,  or  biliary.  Head  and  Sherren  claim  that  the  body  is 
endowed  with  three  forms  of  sensibility  conducted  by  three  series  of  fibers 
in  the  efferent  nerves,  viz. : 

1.  The  nerves  which  subserve  deep  sensibility.     The  fibers  of  deep  sen- 
sibility or  "deep  touch"  course  chiefly  with  the  motor  nerves  to  the  muscles, 

aiding  muscular  protection 
of  viscera,  and  also  supply 
the  fibrous  structures  con- 
nected to  the  muscles — mus- 
cular sense. 

2.  The  nerves  which 
respond  to  painful  impres- 
sions and  to  extreme  heat 
and  cold  responding  to  light 
touch — skin  sense.  This 
second  system  of  nerves 
Head  and  Sherren  term 
"proto  phatic. " 

3.  The  nerves  which  en- 
able light  touch  and  the 
minor  degrees  of  tempera- 
ture to  be  appreciated  and 
two  points  to  be  discrimi- 
nated. 

To  the  third  system  of 
sensibility  the  name  "epi- 
critic"  is  applied — tempera- 
ture and  location  sense. 
The  sensibility  of  the  abdo- 
men is  a  significant  matter  in  sudden  abdominal  pain. 

The  abdominal  cutaneous  sensibility  must  be  distinguished  from  the  sen- 
sibility of  the  abdominal  musculature  and  also  the  condition  as  to  whether  the 
hyperesthenia  be  unilateral  or  bilateral,  symmetrical  or  non-symmetrical,  e. 
g.,  McBurney's  point  is  frequently  simply  a  nervous  point.  At  this  point  the 
nerves  of  the  coecum  correspond  with  the  nerves  of  the  abdominal  wall 
immediately  ventral  to  it,  i.  e.,  the  appendicular  nerves  being  irritated  trans- 
mit sensations  to  the  spinal  cord  where  reorganization  occurs  and  the  impulses 
are  emitted  over  the  intercostal  nerves  to  the  abdominal  wall  at  McBurney's 
point.  The  same  condition  will  occur  relative  to  other  viscera,  e.  g.,  the 
kidney. 

Pain  may  be  reflex  or  sensitive,  hyperesthesia,  neurosthenia,  hysteria. 


INVAGINATION  OF  ILEUM 

Fig.  88.  This  was  drawn  from  a  child  about  10 
months  old.  At  the  operation,  which  was  on  the  4th 
day,  I  could  not  disinvaginate  the  ileum  without  in- 
flicting irreparable  damage.  The  child  died  12  hours 
later. 


SUDDEN   ABDOMINAL    FALX—ITS   SIGNIFICANCE 


399 


Gastric  ulcer  is  especially  liable  to  manifest  pain  from  cold  drink,  solid 
food. 

In  the  diagnosis  the  pain  is  the  most  important  element  to  both  patient 
and  physician. 

The  anatomic  and  physiologic  side  must  be  studied,  analytically. 

It  may  be  remembered  that  the  dorsal  and  ventral  (parietal)  peritoneum 
is  sensitive  to  trauma  according  to  individuals.  The  healthy  visceral  peri- 
toneum is  not  sensitive  to  trauma.  The  healthy  viscera  may  be  handled 
without  pain. 

Pain  on  abdominal  palpita- 
tion may  arise  from  radiation. 

Subjects  vary  as  to  their  sus- 
ceptibility of  pain. 

Pain  manifests  certain  char- 
acteristics as  facial  expression, 
position  of  body,  muscular  ten- 
sion. 

Sudden  abdominal  pain  de- 
pends on  definite  cause  and  it 
behooves  the  physician  to  dis- 
cover it. 

On  account  of  the  multiple 
viscera,  complex  nerve  supply, 
and  numerous  functions  the  ab- 
domen presents  the  most  abun- 
dant and  varied  pain  of  any  body 
region. 

The  sudden  beginning  of  se- 
vere abdominal  pain  is  frequently 
significant  of  serious  trouble. 

Gastric  Crisis.  So-called 
abdominal  crises  should  be  stud- 
ied with  care  that  life  may  not  be 
placed  in  jeopardy  or  disastrous 
treatment  instituted.  First  and 
foremost  is  the  gastric  crisis  of 
locomotor  ataxia  in  which  the 
patient  is  attacked  with  paroxys- 
mal vomiting  and  severe  gastric 
pain  enduring  from  some  hours  to  several  days  and  may  recur  after  days 
or  weeks.  In  such  cases  the  symptoms  of  tabes  dorsalis  will  aid  the  diagnos- 
tician. 

Nephritic  Crisis,  or  the  so-called  "Dietl's  crisis,"  perhaps  should  be 
considered  as  a  trauma  on  the  nerves,  vessels  and  ureter  of  a  dislocated 
kidney.  Torsion  of  the  nephro-neuro-vascular  pedicle  with  flexion  of  the 
ureter   doubtless   accounts  for  this  rare  phenomenon.     Dietl's  crisis  is  fol- 


ILEO-CCECAL  INVAGINATION 

Fig.  89.  Drawn  from  a  woman  about  38 
years  old.  At  the  first  operation  I  could  easily 
disinvaginate.  The  ileo-ccecal  invagination  re- 
curred some  two  months  later  and  at  the  second 
operation  I  resected  the  coecum  and  reunited  the 
ileum  and  colon.  The  patient  died  some  10  days 
later.  Autopsy  demonstrated  that  invagination 
was  due  to  an  enormous  coecal  ulceration  and  the 
colon  was  beset  with  perhaps  a  dozen  ulcers 
from  the  dimension  of  a  dime  to  that  of  a  silver 
dollar.     1,  Coecum  and  appendix.     II,  ileum. 


400  THE  ABDOMINAL  AND  PELVIC  BRAIN 

lowed  by  local  tenderness  in  the  renal  region,  hence,  infection  occurred  in  the 
peritoneum. 

Gas  in  the  tractus  intestinalis  is  a  frequent  accompaniment  of  abdominal 
pain.  However,  the  presence  of  the  gas  does  not  produce  the  pain,  as  that  is 
mainly  due  to  trauma,  stretching  of  the  inflamed  nerves  in  the  peritoneal 
sheet. 

LOCATION   OF   ABDOMINAL   PAIN. 

How  far  can  we  diagnose  abdominal  pain  by  its  locality?  Only  to  a 
limited  degree.  Associated  circumstances  must  aid  in  the  diagnosis.  There 
are  three  common  localities  of  acute  abdominal  pain  or  peritonitis,  viz., 
pelvic,  appendicular  and  that  of  the  gall-bladder  region;  and  as  probability 
is  the  rule  of  life,  it  is  well  to  diagnose  acute  abdominal  pain  as  a  disturbance 
in  one  of  these  three  localities  of  the  peritoneum  until  proved  otherwise. 

Acute  abdominal  pain  in  general  is  referred  to  the  umbilicus — in  other 
words,  the  region  immediately  over  the  solar  plexus  or  abdominal  brain,  the 
receiver  of  the  impressions  of  abdominal  viscera.  Acute  abdominal  pain  is 
generally  due  to  a  disturbance  of  the  peritoneum,  owing  to  a  lesion  of  an 
adjacent  viscus;  but  since  the  peritoneal  lesion  can  arise  from  many  organs 
and  from  several  points  of  the  same  organ,  it  demands  the  most  experienced 
diagnostic  acumen  and  the  most  mature  judgment  to  interpret  the  significance 
of  the  lesion  through  the  abdominal  wall.  No  one  can  decide  what  kind 
of  wood  lies  under  a  table  cloth.  I  have  repeatedly  observed  in  appendicitis 
that  patients  say  the  acute  pain,  especially  in  the  beginning,  is  over  the 
whole  middle  of  the  abdomen  (solar  plexus).  This  may  be  due  to  excessive 
and  violent  peristalsis  of  the  enteron.  As  regards  locating  the  pain  at  any 
point  of  the  enteron,  it  cannot  be  done,  first,  because  the  loops  of  intestines 
have  no  distinct  order  as  to  locality;  second,  the  patient  cannot  discriminate 
a  point  of  pain  at  any  given  locality,  perhaps  from  lack  of  practical 
experience. 

Pain  in  a  particular  area  does  not  invariably  signify  that  the  cause  of  the 
pain  is  located  in  that  region.     The  absence  of  pain  in  regions  is  significant. 

Though  pain  in  the  umbilical  region  be  indeterminate  of  location,  it  is 
frequently  the  knell  of  distress  in  peripheral  visceral  lesion  as  appendix, 
oviduct,  invagination,  axial  relation. 

However,  a  kind  of  sudden  severe  abdominal  pain  may  arise  from  violent 
irregular  peristalsis  (rhythm)  in  non-inflamed  (or  slightly  inflamed)  tubular 
viscera,  as  foreign  bodies  (hepatic,  pancreatic,  ureteral,  intestinal  calculus) 
as  strictures  (intestinal,  ureteral,  biliary,  pancreatic  ducts,  appendix, 
oviducts). 

In  sudden  abdominal  pain  (especially  peritonitic  extravasation)  four 
factors  may  be  observed,  viz. :  (a)  (Sympathetic),  First,  diffuse  pain  in  the 
central  abdomen,  umbilical  region,  solar  plexus,  the  three  abdominal  sensory 
areas,  cutaneous,  peritoneal  and  muscular  are  affected,  shocked.  The  bed 
clothing  cannot  be  tolerated  (sensory,  skin)  and  the  abdominal  muscles 
are  rigid — muscular  visceral  protection. 


SUDDEN  ABDOMINAL   PAIN— ITS  SIGNIFICANCE 


401 


(b)  Later   localization   of   the   pain   occurs   over   the   affected    viscera 
(peritonitis). 

(c)  (Spinal  nerves)  Rigidity  of  abdominal  muscles  arise  over  affected 
viscus  (somatic  muscular,  protection  of  viscera). 

(d)  Hyperesthesia  of  the  skin  over  the  affected  viscus  (somatic  cutaneous, 
protection  of  viscera). 

It  must  be  noted  that  cutaneous  or  sensory  manifestations  of  somatic 
spinal  and  visceral  nerves  may  extend  over  their  entire  periphery,  e.  g.,  in 
appendicitis,  hyperesthesia  or  supersensitiveness  of  the  skin  may  be  found 
in  the  right  iliac  fossa,  over  the  pubis,  pudendum,  Poupart's  ligament,  and 
the  testicle. 

In  regard  to  the  location  of  sudden  acute  abdominal  pain  we  have  to 


Fig.  90.  An  illustration  to  expose  the  progressive  steps  of  uterine  invagination 
(intussusception  or  inversion)  from  the  depression  at  1,  to  the  completed  process  at  2.  1, 
is  where  the  invagination  begins.  2,  presents  the  progressive  steps  of  the  fundal  progress 
through  the  os  uteri.  3,  the  vaginal  fornices  subsequent  to  the  uterine  invagination ;  the 
cervix  presents  a  vigorous  rigid  ring,  resembling  a  giant  anal  sphincter,  with  steady, 
continuous,  vigorous  pressure  on  the  invaginated  portion  of  the  uterus ;  the  rigid  cervical 
ring  gradually  yields,  dilates  and  the  uterus  disinvaginates  like  a  spring.  The  uterus 
becomes  reduced  like  a  dislocated  joint.  Hence,  like  intestinal  invaginations  and  volvulus, 
the  uterus  may  tend  to  reinvaginate. 

consider  (a)  the  seat  of  pain  as  felt  by  the  patient;  (b)  the  pain  elicited  by 
pressure  (tenderness);  (c)  local  rigidity  of  the  abdominal  muscles;  (d)  anes- 
thetic or  hyperesthetic  condition  of  the  skin  of  the  abdomen. 

As  to  local  tenderness  of  pain  elicited  by  pressure,  it  indicates  a  patho- 
logic condition  of  viscus  or  of  the  peritoneum  (inflammatory).  The  pain  is 
induced  by  motion  or  disturbance  communicated  to  a  sensitive  inflamed  area, 
peritoneum. 

Local  rigidity  of  abdominal  muscles  indicates  adjacent  disease  of  organs 
supplied  by  the  same  nerves  as  the  muscles  which  exercise  a  protective 
agency,  to  preserve  rest  for  damaged  tissue,  to  assume  repair,  and  to  pre- 
vent further  damage  from  motion,  e.  g.,  distribution  of  sepsis  by  peristalsis. 
Hyperesthesia  or  sensitiveness  of  the  skin  due  to  transmitted  irritation,  is 
often  present,   but  is  not  very  reliable  as  to  locality,  for  it  is  dependent  on 

26 


402  THE  ABDOMINAL  AND  PELVIC  BRAIN 

peculiar  symptoms  and  accompanies,  more  or  less,  though  irregularly,  most 
acute  abdominal  affections.  Of  course  it  would  be  expected  that  the  severe 
sudden  onset  of  pain  in  the  renal  and  biliary  ducts,  being  very  near  the 
abdominal  brain,  would  be  difficult  to  separate  from  the  solar  plexus.  Lead 
colic  may  deceive  the  most  elect  as  to  its  etiology  or  seat. 

With  few  exceptions,  to  locate  the  seat  of  lesion  in  acute  abdominal 
pain,  we  call  to  aid  the  pain  elicited  by  pressure.  Pressing  the  abdominal 
walls  produces  a  distinct  localized  tenderness  or  pain  which  suggests  local- 
ized pathology.  Again,  rigidity  or  tension  of  the  abdominal  wall  is  suggest- 
ive of  pathologic  locality.  The  symptom  is  simply  purely  reflex,  due  to 
irritation  passing  from  the  involved  viscera  to  the  spinal  cord,  whence  its 
irritation  is  transmitted  to  the  periphery  of  the  distal  intercostal  nerves  which 
control  the  abdominal  muscles  over  the  seat  of  pain.  Dashing  cold  water 
on  the  belly  will  produce  similar  protective  muscular  rigidity.  Hence,  in 
general,  the  location  of  the  disease  in  the  abdomen  from  the  patient's 
feeling  of  sudden  acute  pain,  is  quite  indefinite.  But  local  tenderness  and 
local  pain  on  pressure  aid  much.  Localized  rigidity  of  the  abdominal  wall 
is  suggestive  that  such  tension  is  protecting  the  seat  of  disease  from  motion, 
further  bacterial  or  fecal  invasion.  In  short  the  rigid  muscles  are  placing 
the  pathologic  parts  to  anatomic  and  physiologic  rest. 

Vomiting  is  a  general  characteristic  of  sudden  acute  abdominal  pain.  In 
sudden  acute  abdominal  pain,  from  visceral  lesion,  Nature  makes  profound 
effort  to  manifest  its  distress,  however  to  diagnose  the  seat  of  pathology  and 
its  nature  from  localization  of  the  pain  requires  much  reading  between  the 
lines  from  experience  and  judgment. 

Again,  a  vast  difference  exists  between  sudden  acute  abdominal  pain 
and  that  which  progresses  gradually.  Much  depends  on  the  stage  of  the 
disease  in  which  the  physician  first  visits  the  patient. 

The  signification  of  sudden  acute  abdominal  pain  may  be  more  actually 
realized  by  a  short  consideration  of  some  of  the  principal  conditions  which 
occasion  it. 

In  some  cases  the  physician  is  unable  to  localize  the  pain  in  any  visceral 
tract  under  such  conditions,  the  apt  remark  is  that  probability  is  the  rule  of 
life;  hence  an  exploratory  operation  in  the  region  of  the  appendix  and  gall- 
bladder is  justifiable  in  subjects  jeopardized  by  imminent  danger.  The  most 
frequent  point  of  pain  or  pressure  is  the  epigastrium,  the  abdominal  brain  or 
plexus  coeliacus. 

REFLEX  OR  REFERRED  PAIN. 

In  general,  sudden  acute  abdominal  pain  is  referred  by  the  patient  to  the 
umbilical  region,  to  the  solar  plexus,  directly  over  the  abdominal  brain.  This, 
in  my  opinion,  is  a  nervous  center,  possessing  the  power  of  reorganization, 
of  receiving  and  transmitting  forces,  controlling  visceral  circulation  and 
inducing  reflex  or  referred  pain.  The  irritation  of  peripheral  visceral  nerves 
is  transmitted  to  the  abdominal  pain,  when  reorganization  may  localize 
the  pain  over  the  abdominal  brain,  at  the  seat  of  disease,  or  at  a  remote 


SUDDEN   ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


4.03 


abdominal  point,  due  to  a  supersensitive  nervous  system.  Anal  fissure,  or 
ulcer,  is  one  of  the  most  typical  examples  to  produce  reflexes  in  the  abdom- 
inal viscera,  especially  in  the  tractus  intestinalis.  Short  trauma  of  viscera,  as 
hernia,  acute  flexion  of  tubular  viscera,  induces  abdominal  pain  and  especially 
by  reflexes. 

OBSCURE  SYMPTOMS  OF  ABDOMINAL  PAIX. 

Reflex  pain  from  distant    areas    may  simulate    severe  abdominal  pain, 
multiplying  the  difficulties  in  differential  diagnosis. 

Obscure    symptoms  of  abdominal    pain  arise  from  the  invasion  of  the 


Fig.     91.     An    illustration   presenting  complete    uterine    invagination.     The    oviducts 
and  ovaries  may  be  entirely  included  within  the  invaginated  uterus.     1,  ovary ;  2,  oviduct ; 
3,  round  ligament;  4,  uterine  fundus  with  diamond-shaped  aperture  resected  from  its  wall  ; 
5,  vaginal  lumen.     Drawn  from  subject  dying  from  trauma,  shock,  due  to  uterine  invaginatic 
2J/2  hours  subsequent  to  labor.     I  performed  the  autopsy  4  hours  after  death. 

peritoneum  from  pneumonia.  In  fact  I  have  seen  a  half  dozen  physicians  i 
consultation  advise  and  perform  peritonotomy  in  a  case  of  pneumonia,  s 
deceptive  were  the  abdominal  symptoms — pain,  tenderness,  tympaniti 
temperature,  muscular  rigidity  and  respiration. 

Pleurisy  or  intercostal  neuralgia  extending  over  a  large  area  of  inte  - 
costal  nerves  which  supply  the  abdominal  wall  may  simulate  sudden  abdom- 
inal pain — for  the  trunk  of  a  nerve  being  irritated  manifests  its  sensation, 
pain,  at  its  periphery  which,  in  the  case  of  the  intercostal,  end  in  the  abdominal 
wall. 


404 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


Abscess  in  the  abdominal  wall  may  simulate  abdominal,  peritoneal  or 
visceral  pain,  from  irritation  of  the  intercostal  (abdominal  wall)  nerves.  Dr. 
Lucy  Waite  had  in  her  charge  in  the  hospital  a  child  with  an  abscess  in  the 
abdominal  wall  which  simulated  extremely  abdominal  visceral  (peritoneal) 
disease. 

Amygdalitis  mastitis  and  hysteria  may  simulate  abdominal  pain. 

In  post-operative  peritoneal  hemorrhage  (peritoneal  extravasation)  the 
pain  is  obscure,  as  the  previously  traumatized,  and  consequently  obtunded, 

sensibility  of  the  peritoneum  does 


not  manifest  recognition  of  the 
bleeding,  while  peritoneal  hem- 
orrhage (peritoneal  extravasation) 
from  ruptured  pregnant  oviduct 
produces  excruciating  pain. 

Spinal  cord  lesions  may  sim- 
ulate abdominal  pain  by  a  diffuse 
sensitiveness  over  the  affected 
intercostal  nerves,  e.  g.,  the  gir- 
dle, constricting  pain  in  tabes 
dorsalis  or  locomotor  ataxia. 

Uremia  may  be  accompanied 
by  persistent  vomiting.  Pain  in 
right  shoulder  may  refer  to  he- 
patic disease. 

Spinal  caries  may  produce 
pain  in  portions  of  the  abdomen 
from  pressure  on  dorsal  or  lumbar 
nerves,  as  sensory  areas  or  rigid 
muscular  areas. 

Testicular  pain  may  refer  to 
a  ureteral  calculus.  Crushed  tes- 
ticle may  induce  severe  abdom- 
inal pain,  vomiting  and  shock,  as 
its  route  to  the  abdominal  brain  is 
direct  and  rich  in  nerves. 

Hyperesthesia  of  the  iliac  re- 
gions are  deceptive,  because  these 
regions  are  supplied  by  the  cuta- 
neous branches  of  the  ileo-hypogastric  nerve  (first  lumbar).  McBurney's 
point  is  practically  a  skin  hyperesthesia,  a  super-sensitiveness  of  skin  area 
included  in  the  peripheral  region  of  cutaneous  twigs  of  the  last  dorsal 
(twelfth  intercostal)  nerve  and  the  ileo-hypogastric  (first  lumbar)  nerve. 

In  short,  if  any  sensory  intercostal  or  lumbar  nerve  be  affected  (by  somatic 
diseased  viscera)  it  will  manifest  sensory  skin  areas  at  its  corresponding 
periphery. 

Muscular  rigidity  of  the  abdominal  wall  will  be  manifest  in  the  somatic 


VOLVULUS  OF  SIGMOID 

Fig.  92.  Drawn  from  a  subject  with  physio- 
logic or  incomplete  sigmoid  volvulus.  Z,  Sig- 
moid.    The  volvulus  is  rotated  about  360  degrees. 


SUDDEN   ABDOMINAL   PAIN— ITS   SIGNIFICANCE 


405 


area  of  the  spinal  nerves  corresponding  to  the  diseased  viscera  (simulating 
the  cutaneous  area).  In  short,  if  any  motor  intercostal  or  lumbar  nerve  be 
affected  (by  somatic  diseased  viscera)  it  will  manifest  motor  (muscular  rigidity) 
area  at  its  corresponding  periphery. 

A  feature  of  obscurity  in  the  diagnosis  in  abdominal  muscular  rigidity  is 
that  when  a  part  of  an  abdominal  muscle  becomes  irritated,  the  whole  (and 
not  part)  of  the  muscle  becomes  rigid.  Hence  the  muscular  rigidity  is  the  same 
for  perforated  appendix  or  gall-bladder.  For  general  peritonitis  the  whole 
abdominal  muscular  apparatus  is 
rigid. 

In  the  tractus  nervosus  the 
neuroma  of  intercostal  or  lumbar 
nerves  must  not  be  overlooked. 
I  have  observed  three  subjects  of 
neuroma  on  the  ileo-hypogastric 
or  ileo-inguinal  nerve.  One  in 
Prof.  Senn's  clinic  where  a  neu- 
roma on  a  nerve  in  the  abdominal 
wall  in  the  region  of  the  appendix 
was  exquisitely  tender  inducing  a 
diagnosis  of  appendicitis.  The 
analytic,  searching  diagnostic 
methods  of  Prof.  Senn  soon 
discovered  the  tender  neuroma, 
which  he  removed  instead  of  the 
appendix.  One  subject,  a  female, 
24  years  of  age,  was  sent  to  me 
with  a  diagnosis  of  appendicitis. 
I  found  a  typical  neuroma  on  the 
lumbar  nerve  in  the  region  of 
the  appendix.  A  third  case  of 
neuroma  of  a  lumbar  nerve  in 
the  appendicular  region  I  saw  in 
consultation  with  Dr.  I.  Wash- 
burn, of  Rensselaer,  Indiana. 
Abdominal  pain  is  the  surface 
indication  of  various  pathologic 
states  of  the  abdominal  organs  (or 
abdominal  wall).  In  abdominal  pain  the  chief  skill  is  in  the  diagnosis,  for  the 
correct  treatment  depends  on  the  diagnosis.  The  more  correct  the  diagnosis 
the  less  "neurosis"  will  occur  in  abdominal  pain.  The  abdominal  wall, 
including  the  cutaneous  and  muscular  layers,  receives  its  (chief)  nerve  supply 
from  the  spinal  cord,  which  contains  sensor}r  and  motor  nerves.  The  viscera 
receive  their  (chief)  nerve  supply  from  the  sympathetic,  which  contain  sensory 
and  motor  (rhythmic).  (The  parietal  peritoneum  has  a  mixed  nerve  supply.) 
The  spinal  cord  emits  nerves  through  the  rami  communicantes  to  the  viscera 


VOLVULUS  OF  SIGJvlOID 

Fig.  93.  Drawn  from  a  subject  with  physio- 
logic or  incomplete  sigmoid  volvulus  which  is 
360  degrees  rotated. 


406 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


and  receives  nerves  from  the  viscera.  The  spinal  cord  emits  nerves  to  the 
abdominal  wall  (muscle  and  skin).  Hence  the  viscera  and  abdominal  wall  are 
in  direct,  harmonious,  balanced  relations  and  consequently  of  vast  value  in 
diagnosis.  Any  visceral  disorder  is  reported  to  the  spinal  cord  which  is  at 
once  emitted  to  the  abdominal  wall  for  protective  purposes  (muscular  rigid- 
ity). The  visceral  walls  are  the  thoracic  and  abdominal  and  cannot  be  divided 
— they  are  supplied  by  the  spinal  nerves  which  overlap,  extending  from  clavicle 

to  pelvic  floor. 

Man's  breathing  apparatus  con- 
sists of  the  thoracic  and  abdominal 
wall.  The  thoracic  visceral  rhythm 
(sympathetic)  dominates  in  the  tho- 
racic wall. 

All  the  visceral  tracts  except  the 
nervous  may  manifest  painful  peri- 
stalsis from  inflamed  ducts  or  canals. 


STRANGULATION    BY   BANDS   AND 
THROUGH    APERTURES. 

Strangulation  by  bands  and 
through  apertures  constitutes  one- 
third  of  all  intestinal  obstructions. 
If  the  bowel  loops  glide  through  an 
inguinal  or  femoral  aperture,  digital 
examination  will  detect  the  cause  of 
sudden,  acute  abdominal  pain.  Ob- 
turator and  sacro  sciatic  hernia  are 
seldom  diagnosed,  so  that  they  would 
practically  be  included  in  internal 
strangulation  by  peritoneal  bands. 
Sex  does  not  aid  in  diagnosis,  for 
males  and  females  about  balance  in 
peritonitis  during  life,  hence  will 
possess  about  the  same  amount  of 
peritonitic  bands. 

A  history  of  previous  peritonitis 
tells  a  significant  story  of  strangula- 
tion by  bands.  Vomiting  is  violent, 
pain  from  peristalsis  is  periodic  and  general  over  the  abdomen.  The  pain  is 
not  due  to  checking  of  the  fecal  current,  but  to  reflex  irritation  of  the  bowel 
at  the  seat  of  obstruction.  Temperature  is  not  conspicuous  and  the  pulse 
is  not  much  changed.  Tympanitis  arises  in  exact  proportion  to  the  peristal- 
sis of  the  bowel  wall  proximal  to  the  seat  of  obstruction.  At  first  the  pain  is 
violent,  but  it  subsides  with  the  progress  of  the  case,  becoming  more  contin- 
uous and  generally  diffused.  If  the  patient  be  quiet,  the  pain  is  so  slight 
that  it  deceives  the  most  elect.     No  stool,   no  gas  per  rectum,  no  detectible 


VOLVULUS  OF  ILEO-CCECAL 
APPARATUS 

Fig.  94.  Drawn  from  subject  with  phys- 
iologic or  incomplete  volvulus  of  the  ileo- 
coecal  apparatus.  I,  presents  the  state  of  the 
volvulus — about  200  degrees. 


SUDDEN   ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


407 


swelling  at  any  hernial  aperture  with  continuous  abdominal  pain  and  vom- 
iting, demand  surgical  notice.  The  temperature  and  pulse  are  not  reliable. 
Strangulation  by  bands  will  generally  give  no  tender  location  on  pressure  and 
no  detectible  swelling;  and,  in  fact,  I  have  watched  cases  with  the  abdomen 
quite  soft  and  pliable,  with  no  possible  physical  point  of  diagnostic  value, 
not  even  tympanitis,  yet  with  obstruction  which  proved  gangrenous  on  peri- 
tonotomy.  In  one  case  the  pain  was  at  first  severe,  general,  and  almost 
subsided  the  day  before  the  operation,  yet  fifteen  feet  of  intestine  was  as  red 


ENTERONIC  VOLVULUS 


Fig.  95.  Drawn  from  a  child  14  months  old,  referred  to  me  by  Dr.  Walter  Fitch.  I 
operated  on  the  third  day  and  found  the  pedicle,  foot  or  style,  of  the  volvulus  to  be  located 
at  the  coecum,  the  constriction  being  due  to  the  rotation  of.  the  distal  end  of  the  ileum  and 
proximal  end  of  the  jejunum  around  each  other  as  an  axis.  On  opening  the  abdomen  the 
colon  was  collapsed  while  the  enteron  was  enormously  distended.  After  releasing  the  vol- 
vulitic  pedicle  the  gas  rapidly  distended  the  entire  colon  and  large  volumes  with  ample  stool 
passed  per  rectum.  The  child  died  of  peritonitis  3  days  later.  4,  Volvulitic  pedicle  of 
enteron. 

as  sunset.  The  sudden,  acute  abdominal  pain  is  not  due  to  the  constricting 
band,  but  to  reflex  irritation  transmitted  to  the  abdominal  brain,  where 
reorganization  occurs,  whence  it  is  emitted  to  the  whole  digestive  tract, 
inducing  violent,  disordered  and  wild  peristalsis  (colic). 

Acute,  sudden  abdominal  pain,  due  to  a  constricting  peritoneal  band  is 
one  of  the  most  obscure  to  interpret.  To  explore  the  abdomen  in  the  proper 
time  for  such  a  case  requires  a  wise  diagnostician  and  a  bold  surgeon.  The 
matters  to  bear  in  mind  by  strangulation  by  bands  are,  the  acute,  sudden 
abdominal    pain    with    a   violent   onset,    vomiting,  and  the   distinct  colicky, 


408 


THE  ABDOMINAL  AND  PELVIC  BRAIX 


peristaltic, periodic  character  of  the  suffering,  not  forgetting  a  previous  his- 
tory of  peritonitis.  However,  the  sudden,  acute  abdominal  pain,  arising  from 
a  strangulation  of  a  loop  of  bowel  by  peritonitic  bands,  is  difficult  to  interpret 
and  seldom  diagnosed.  It  may  be  asserted,  that  when  a  patient  is  suffering 
from  some  grave  disease,  manifest  by  sudden  acute  abdominal  pain,  the 
nature  of  which  cannot  be  interpreted,  an  early  exploratory  laparotomy  is 
justifiable  and  demanded.     Such  obscure  cases  require  an  experienced  surgeon, 

skilled  in  abdominal  work,  to 
meet  any  emergency,  to  enter  the 
peritoneum  and  retire  rapidly.  I 
remember  very  distinctly  the  case 
of  a  man,  about  40,  who  gave 
consent  to  my  colleague,  a  gen- 
eral practitioner,  who  was  entirely 
untrained  by  experience  or  obser- 
vation in  abdominal  surgery.  The 
doctor  told  me  he  opened  the 
abdomen  and  found  a  band 
stretching  tightly  across  the  right 
colon.  But  he  said  "the  colon 
was  black,  and  I  did  not  know 
what  to  do  with  it,  so  I  closed 
the  abdomen."  It  is  needless  to 
say  that  the  man  made  a  prompt, 
fatal  exit.  But  most  cases  die 
undiagnosed.  The  danger  of 
strangulation  by  bands  is  gan- 
grene and  perforation. 

The  starting  point  of  peri- 
toneal bands  are — (a)  local  peri- 
tonitis, (b)  hernial  apertures 
(inguinal,  femoral,  abturator, 
fossa  duodeno-jejunelis,  inter- 
sigmoid  fossa,  Winslow's  fora- 
men), (c)  peritonitis  from 
muscular  trauma  (psoas,  lateral 
abdominal),  (d)  infective  mesen- 
teric glands,  (e)  operative  sites, 
(f)  fimbriated  ends  of  oviducts, 
A  history  of  typhoid  fever,  hernia,  peritonitis  is 


VOLVULUS  OF  ILEO-CCECAL  APPARATUS 

Fig.  96.  Drawn  from  subject  with  physio- 
logic or  incomplete  volvulus  of  ileo-ccecal  ap- 
paratus. X,  shows  the  state  of  the  volvulus— 
almost  360  degrees.  Z,  presents  a  large  pouch  in 
the  mesosigmoid. 


(g)  Meckel's  diverticulum, 
suggestive. 

The  intensity  of  the  abdominal  pain  in  intestinal  obstruction  depends  on 
the  completeness  of  the  obstruction.  The  pain  not  being  inflammatory  is 
paroxysmal,  rythmical,  due  to  trauma  on  the  nerve  periphery  in  the  intestinal 
wall. 

It  should  be  noted  that  reduction  by   taxis  of  a  strangulated   intestine 


SUDDEN   ABDOMINAL    PAIN— ITS   SIGNIFICANCE  409 

in  the  hernial  rings  ought  to  be  practiced  with  care.  The  danger  is  reduc- 
tion in  mass  (without  relief)  and  the  return  into  the  peritoneal  cavity  of 
pathological  intestinal  segments.  In  strangulation,  internal,  it  is  well  to 
inquire  whether  a  patient  has  suffered  from  peritonitis  or  experienced  peri- 
tonotomy. 

In  strangulation  of  an  intestinal  loop  the  symptoms  will  practically 
simulate  perforation  or  extravasating  peritonitis  only  after  the  sepsis  has 
begun. 

Hernia  which  may  involve  several  visceral  tracts  (digestive,  genital, 
urinary)    not  infrequently  presents  unsuspected   irritation  from  the   natural 


POSITIONS  OF  THE  APPENDIX 

Fig.  97.  Pelvic  position  (woman  47  per  cent — man  37  per  cent).  2,  Retro-coecal  position 
(20  per  cent).  3,  Potential  position  (23  per  cent).  4,  Right  of  psoas  (18  per  cent).  4,  Resting 
on  the  psoas  (46  per  cent). 

hernial  rings  from  the  inimical  supraumbilical  hernia  in  the  linea  alba. 
I  have  observed  much  distress  and  suffering  in  patients  afflicted  with  hernia 
which  had  been  overlooked  for  years. 

I  assisted  Dr.  Lucy  Waite  to  operate  on  a  woman  some  35  years  of  age, 
on  whom  a  previous  peritoneal  section  had  been  performed.  She  had  suffered 
from  obstruction  of  the  bowels  for  several  days  with  continuous  vomiting. 
Dr.  Waite  found  an  organized  peritoneal  band  of  some  fifteen  inches  in  length 
extending  tensely  across  a  loop  of  intestine  producing  almost  complete 
obstruction.     Rupture  of  the  band  afforded  complete  relief  with  recovery. 

Sudden  obstruction  may  arise  from  intestinal  loops  gliding  to  and  fro 
through  apertures  in  the  mesentery,  omentum. 


410  THE  ABDOMIXAL  AXD  PELVIC  BRAIN 

INVAGINATION. 

Invagination  constitutes  about  one-third  of  all  intestinal  obstruction,  and 
the  sudden,  acute  abdominal  pain  arising  from  this  cause  is  more  easily  inter- 
preted. Age  signifies  much  in  this  case,  for  one-fourth  of  all  invagination 
occurs  before  the  end  of  the  first  year  of  extrauterine  life,  and  one-half  before 
the  end  of  ten  years.  Invagination  is  a  disease  of  childhood.  Its  mode  of 
onset  is  sudden  and  frequently  violent.  From  some  twenty-five  experiments 
in  invaginating  the  bowel  of  the  dog,  I  am  sure  the  pain  is  periodic  at  first. 
The  griping,  colicky  peristalsis  is  rhythmic,  depending  on  irritation.  At  stated 
times  the  dog  suddenly  spreads  wide  his  four  feet  and  arches  his  back,  appear- 
ing in  severe  distress,  then  gradually  recovers  his  natural  attitude.  In  invagi- 
nation blood  occurs  in  the  stool  in  80  per  cent  of  cases  (especially  children), 
and  the  vomiting  is  not  violent,  nor  even  always  conspicuous,  for  the  bowel 
is  only  partially  occluded.  Seventy  per  cent  occur  at  the  ileocecal  appar- 
atus, that  land-mark  in  man's  clinical  history,  15  per  cent  in  the  enteron  and 
15  in  the  colon.  Invagination  manifests  abdominal  pain  similar  to  an  elongated 
enterolith  in  the  bowel,  which  in  rotating  leaves  small  spaces  at  its  side  for 
the  passage  of  gas  and  some  liquid  stool.  I  have,  unfortunately,  watched 
a  case  of  enterolith  day  after  day,  with  some  half  dozen  physicians,  not 
becoming  able  to  interpret  the  abdominal  pain  or  to  diagnose  the  case,  until 
gangrene  of  the  bowel  occurred  at  the  seat  of  the  enterolith,  when  nature 
asserted  manifestation  to  induce  us  to  explore  the  abdomen,  but  with  a  fatal 
result.  The  most  skilled  of  abdominal  surgeons  repeatedly  examined  this 
case,  but  could  not  interpret  the  acute  abdominal  pain,  which  came  on  sud- 
denly, though  as  the  days  glided  it  quietly  subsided.  The  patient  was  a 
physician,  but  could  not  localize  any  abdominal  pain;  it  was  diffuse.  Tem- 
perature was  about  99J  S  deg.  and  100  deg.  F.,  and  the  pulse  was  65  to  95, 
almost  the  whole  week  of  illness.  The  abdomen  was  generally  soft  and  not 
tympanitic.  Very  seldom  can  abdominal  tumor  be  palpated  in  bowel  invagi- 
nation. Shock  in  young  children  is  quite  conspicuous,  yet  I  personally  know 
of  two  autopsies  in  infants,  who  were  attended  in  life  by  three  of  the  most 
skilled  abdominal  surgeons,  yet  the  post-mortems  revealed  invagination  as 
the  cause  of  death.  A  skilled  and  experienced  physician,  such  as  the  late  Dr. 
Jaggard  was  called  to  an  eight  months  infant  and  he  stripped  the  clothing  to 
be  more  thorough  in  examination,  and  yet  after  all  his  diagnostic  skill,  failed 
to  locate  disease  in  the  digestive  tract  from  lack  of  symptoms.  The  child 
was  very*  pale,  cried  a  little,  and  died  thirty  hours  after  the  attack.  The 
autopsy  revealed  ileocecal  invagination. 

Sudden  acute  abdominal  pain  in  a  child  may  with  high  probability  be 
interpreted  as  invagination,  especially  if  one  can  detect  the  periodic,  peristal- 
tic character,  its  colicky  nature.  Blood  following  in  the  stool  is  almost 
pathognomonic.  A  tumor  will  rarely  be  found,  and  pressure  on  it  will  not 
generally  elicit  tenderness,  it  is  not  at  all  likely  the  patient  can  locate  the 
seat  of  the  disease  from  pain.  Tympanites  and  vomiting  are  not  conspicuous, 
and  the  temperature  and  pulse  are  not  reliable.  The  danger  of  invagination 
is  sloughing  of  the  apex  or  neck  and  consequent  perforation  and  peritonitis. 


SUDDEN   ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


411 


Invagination  presenting  at  the  anus  interprets  easily  the  cause  of  pain. 

Tenesmus  is  a  prominent  feature.  In  quite  a  number  of  cases  of  invag- 
ination during  the  last  fifteen  years  I  could  palpate  a  tumor  but  twice,  and 
that  was  once  in  an  adult,  spare  woman  where  the  ileocecal  invagination  had 
progressed  to  the  flexura  coli  lienalis.  The  cause  of  her  invagination  was  a 
large  ulcer  of  the  cecum,  which  extensively  hypertrophied  the  cecal  wall. 
I  disinvaginated  the  cecum;  however,  reinvagination  occurred  some  weeks 
later  when  resection  of  the  cecum  was  practiced  with  fatal  result.  Once  I 
could  palpate  an  invaginated  tumor  in  a  child. 


r^^^ti— 


POTENTIAL  POSITION  OF  APPENDIX 


Fig.  98.     The  appendix  rests  among  the  enteronic  coils;   however,  on  rupture  it  would 
be  protected  by  the  omentum. 


In  actual  practice  we  found  at  the  Mary  Thompson  Hospital  for  women 
and  children  that  shock  was  the  chief  fatal  factor — the  children  entering  the 
hospital  with  advanced  invagination,  when  peritonitis  had  begun  and  the 
pulse  was  uncountable. 

From  fifteen  years  of  observation  on  infant  invagination,  as  they  enter 
the  hospital  in  an  advanced  or  late  stage  of  the  disease,  I  am  convinced  that 
on  the  average,  more  infants  will  recover  from  intestinal  invagination  with- 


412  THE  ABDOMINAL  AND  PELVIC  BRAIN 

out  an  operation  than  with  one.     I  think  actual  cases  by  number  will  prove 
this  claim — sound  unsurgical  as  it  may. 

Slowly  progressing  stricture  may  suddenly  become  closed. 

VOLVULUS. 

Volvulus  is  so  rare  that  it  constitutes  about  one-fortieth  of  all  intestinal 
obstructions,  and  occurs  mainly  in  men,  as  women  and  children  are  practi- 
cally free  from  sigmoid  volvulus.  As  in  invagination  so  in  volvulus,  I  was 
always  compelled  to  suture  them  in  position  in  a  dog.  But  I  never  succeeded 
in  establishing  a  permanent  volvulus  in  the  dog.  Volvulus  is  characterized  by 
tympanites,  and  it  is  said  by  periodic  pain.  Volvulus  occurs  at  the  sigmoid  in 
60  per  cent  of  subjects,  at  the  ileocecal  valve  in  30  per  cent,  and  in  the  small 
intestines  in  10  per  cent.  It  is  so  rare  that  though  I  have  seen  several  cases 
of  partial  (physiologic)  volvulus,  however  only  one  case  of  complete  (patho- 
logic) volvulus  in  man.  The  subject  of  enteronic  volvulus  was  in  a  male 
child  brought  to  me  by  Dr.  Walter  Fitch.  He  was  in  the  third  day  of  illness. 
I  operated  and  relieved  the  volvulus  of  the  enteron  but  the  child  died  of 
shock  and  infection  three  days  later.  Nicholas  Senn  operated  successfully 
on  a  man,  on  the  eighth  day,  for  sigmoid  volvulus.  He  introduced  a  tuck 
plication  in  the  mesosigmoid  for  prophylaxis.  Seven  years  later  another 
physician  operated  on  the  same  man  for  volvulus,  recurrence,  with  fatal 
result.  The  man  had  enormous  tympanites;  his  pain  is  not  described  as 
severe,  but  no  doubt  the  suffering  is  severe. 

At  first  the  pain  is  periodic  but  as  time  advances  it  becomes  more  con- 
stant, with  now  and  then  exacerbations.  Vomiting,  though  not  conspicuous, 
must  arise  more  or  less  from  trauma  to  the  peritoneum.  Perhaps  the  sudden 
pain,  chronic  constipation,  and  rapid  rise  of  tympanites  would  aid  in 
interpreting  volvulus,  but  seldom  can  one  diagnose  such  a  disease  from  its 
rarity.  Pain  no  doubt  would  be  referred  to  the  abdominal  brain.  Most 
clinicians  note  tympanites  as  a  conspicuous  feature  of  volvulus. 

Weller  Van  Hook  treated  successfully  a  case  of  sigmoid  volvulus  of 
eight  days'  standing. 

From  observation  of  the  sigmoid  and  mesosigmoid  in  hundreds  of  autop- 
sies I  am  convinced  that  the  chief  etiology  of  volvulus  of  the  sigmoid  is 
elongated  sigmoid  located  in  the  proximal  abdomen  and  possessing  a  narrow 
foot  accompanied  by  mesosigmoiditis  due  to  vigorous  action  of  the  left  psoas 
muscle  which  traumatizes  the  sigmoid,  inducing  migration  of  germs  or  their 
products  through  mucosa,  muscularis  into  the  serosa,  inciting  plastic  peri- 
tonitis in  80  per  cent  of  adults. 

The  plastic  peritonitis  in  general  ends  in  two  conditions,  viz. :  1.  The 
most  frequent,  the  plastic  sigmoiditis  binds  the  left  surface  of  the  mesosig- 
moid to  the  ventral  surface  of  the  psoas  muscle.  Such  subjects  cannot 
have  sigmoid  volvulus  from  mechanical  condition.  2.  The  second  state  of 
the  mesosigmoid  arising  from  the  mesosigmoiditis  is  a  progressive  shorten- 
ing, a  contraction  of  the  base  of  the  mesosigmoid,  that  is,  the  base  or  pedicle 
of  the  mesosigmoid    becomes  a  very  narrow  pedicle  from  the  progressing, 


SUDDEN   ABDOMINAL   PAIN— ITS   SIGNIFICANCE 


413 


contracting  mesosigmoiditis,  so  that  peristalsis  of  the  sigmoid  induces  a 
rotation  or  torsion  of  its  base.  In  autopsies  I  have  found  partial  (physio- 
logic) rotation  of  the  mesosigmoid,  especially  during  the  existence  of  mesosig- 
moiditis — as  far  as  180  to  360  degrees. 

Sigmoid  volvulus  is  due  to  the  torsion,  rotation,  of  the  narrow  pedicle  of 
a  mesosigmoid  contracted  at  its  foot  by  mesosigmoiditis.  When  one 
untwists,  detorsionizes,  the  volvulus  and  releases  it,  the  sigmoid  recedes, 
rotates,  like  a  spring  into  its  original  volvulitic  condition.  To  prevent  the 
volvulus  from  returning  to  its  original  torsion  in  dogs  I  sutured  it  in  situ. 
Resection  may  be  required  to  overcome  the  acute  torsion.     Puncture  may 


ABSENCE  OF  APPENDIX  (AND  CCECUM) 
Fig.  99.     Drawn  from   female,   aged   50   years.     The   diagnosis  in   this  case  would   be 


uncertain. 


be  required  to  reduce  its  dimension.  Most  subjects  have  ample  'time  to 
acquire  sigmoid  volvulus,  as  they  are  generally  over  40  years  of  age.  There 
is  frequently  physiologic  sigmoid  volvulus  in  autopsy  which  is  partial  tor- 
sion of  the  mesosigmoid;  however,  obstruction  is  incomplete.  The  marked 
tympanitis  or  meteorism  of  sigmoid  volvulus  is  at  first  localized  in  the 
left  iliac  fossa — a  slight  diagnostic  point.  The  sigmoid  is  the  most  varied  of 
any  segment  of  the  colon  in  location  and  capacity  of  its  lumen.  The  tymp- 
anitis may  be  located  in  the  right  abdomen  while  the  nontympantic  enteronic 
loops  may  be  forced  around  the  constricted  foot  of  the  volvulitic  sigmoid. 
Childhood  is  not  predisposed  to  sigmoid  volvulus,  notwithstanding  the 
relatively  elongated  sigmoid  and  mesosigmoid,  because  the  angle  of  mesosig- 


414 


THE  ABDOMIXAL  AND  PELVIC  BRA IX 


moid  insertion  (what  I  term  von  Samson's  angle)  is  located  well  proximalward 
on  the  lumbar  vertebra.  Why  woman  is  practically  free  from  sigmoid 
volvulus  I  am,  so  far,  unable  to  explain.  Sigmoid  volvulus  occurs  practically 
in  men  possessing  what  I  term  the  "giant  verticle  sigmoid"  which  is  located 

in  the  proximal  abdomen  and  oc- 
curred in  perhaps  15  per  cent  of  the 
autopsies.  The  foot  of  this  giant 
verticle  sigmoid  is  narrow  and  ^by 
the  contracting  mesosigmoiditis  re- 
sults in  a  narrow  style  around  which 
may  rotate  the  sigmoid  loop.  This 
was  the  condition  I  found  in  physio- 
logic volvulus  which  occurred  in  per- 
haps 2  per  cent. 

APPENDICITIS. 

Appendicitis  is  the  most  dan- 
gerous and  treacherous  of  abdom- 
inal diseases — dangerous  because  it 
kills,  and  treacherous  because  its 
capricious  course  cannot  be  prog- 
nosed.  The  peritonitis  it  produces 
is  either  enteronic  (dangerous — ab- 
sorptive, non-exudative)  or  colonic 
(mild — exudative,  non-absorptive). 

A  concise  clinical  history  should 
be  obtained  when  sudden  pain  arises 
in  the  right  side  of  the  abdomen  for 
it  might  be  due  to  perforated  appen- 
dix, gall-bladder  or  gestating  ovi- 
duct. The  right-sided  pain  may 
arise  from  biliary,  pancreatic  or  ure- 
teral calculus  or  ureteral  flexion. 

Pleurisy  or  intercostal  neuralgia 
(right)  may  confuse.  In  the  right 
side,  so  closely  adjacent  are  eight 
important  viscera,  momentous  in 
surgery,  that  a  silver  dollar  will 
touch  the  pylorus,  gall-bladder,  head 
of   the    pancreas,    kidney,    adrenal, 


APPENDIX    LYING  ADJACENT   TO 
MECKEL'S  DIVERTICULUM 

Fig.  100.  This  drawing  was  taken  from  a 
subject  on  whom  I  operated  for  a  large  ab- 
scess in  the  right  iliac  fossa  and  at  the  same 
time  I  removed  a  perforated  tube  3  inches  in 
length  and  of  the  usual  appendicular  dimen- 
sion— supposing  it  to  be  the  appendix.  Three 
months  later  the  man  died  from  appendicitis, 
as  the  postmortem  performed  by  Dr.  Arthur 
MacNeil  demonstrated.  The  first  attack  and 
abscess  was  from  the  perforation  of  Meckel's 
diverticulum,  located  in  the  right  iliac  fossa. 
The  second  attack  and  abscess  was  from  per- 
foration of  the  appendix,  located  (retro-ccecal) 
in  the  right  iliac  fossa. 


duodenum,  ureter  and  possibly  the 
appendix.  Hence  differential  diagnosis  of  sudden  abdominal  pain  in  the 
closely  adjacent  multiple  organs  of  the  right  side  is  difficult — frequently  im- 
possible. 

The  conditions  that  cause  the  excruciating,  agonizing,  shocking  pain  in 
appendicitis  are   perforation  and   extravasation  into  the  peritoneal    cavity. 


SUDDEN    ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


415 


Right-sided  muscular  rigidity  means  that  the  motor  (intercostal)  nerves 
supplying  the  abdominal  muscles  are  irritated.  It  may  be  any  kind  of  peri- 
toneal infection  (extravasation  from  any  viscus,  hepatic,  intestinal,  ureteral  or 
genital).  Right-sided  cutaneous  hyperesthesia  means  that  the  sensory 
(intercostal)  nerves  supplying  the  abdominal  skin  are  affected.  It  may 
depend  on  any  kind  of  peritoneal  infection.  Sudden  cessation  of  severe 
symptoms,  as  rapid  diminishing  of  high  temperature  and  pulse  and  abdo- 
minal rigidity,  is  an  evil  omen — gangrene  of  the  appendix  has  probably  occur- 
red.    Immediate  operation  should  occur. 

For  years  I  have  made  it  a  rule  to  recommend  appendectomy  to  patients 
having  experienced  two  attacks.  Fifty  per  cent  of  subjects  who  have  had 
one  attack  experienced  no  recurrence. 


RELATION  OF  APPENDIX  TO  THE  GENITAL  TRACT 

Fig.  101.  Appendicitis  and  salpingitis  are  separate  diseases,  each  arising  from  its  own 
mucosa.  However,  infection  emanating  from  either  may  compromise  the  anatomy  and 
physiology  of  the  other  by  peritoneal  adhesions. 


In  perforation  it  is  very  difficult  to  interpret  the  sudden  abdominal  pain. 
Associated  circumstances  would  aid.  In  typhoid  fever  one  would  naturally 
suspect  perforation  if  sudden  acute  abdominal  pain  arose,  and  my  colleague, 
Dr.  Weller  Van  Hook,  successfully  operated  on  a  typhoid  perforation  diag- 
nosed by  his  medical  friend.  One  might  think  if  he  was  called  to  a  young 
woman  with  sudden  acute  abdominal  pain  that  it  was  a  round,  perforating 
ulcer  of  the  stomach,  after  excluding  pelvic  and  appendicular  disease,  but  the 
sudden  acute  abdominal  pain  of  perforation  is  so  vague  and  indefinite  that 
only  an  exploratory  incision  would  interpret  it. 

The  sudden  acute  abdominal  pain  from  appendicitis  (perforation)  is  more 
apt  to  be  diagnosed  from  probability.  Now  probability  is  the  rule  of  life, 
and  when  one  is  called  to  a  boy  or  man  with  sudden  acute  abdominal  pain, 


416  THE  ABDOMINAL  AND  PELVIC  BRAIN 

it  is  likely  appendicitis.  The  pain  of  appendicitis  is  at  first  sudden  and 
generally  diffuse,  and  in  appendicitis  this  is,  in  my  experience,  a  character- 
istic and  conspicuous  feature.  The  sudden  acute  pain  in  appendicitis  is 
doubtless  due  to  violent  appendicular  peristalsis  (colic)  of  an  inflamed 
appendix,  or  to  the  rupture  allowing  the  bowel  contents  to  come  in  contact 
with  the  peritoneum,  and  also  inducing  violent  irregular  peristalsis  of  the 
adjacent  bowel  loops.  It  is  the  agonizing,  excruciating  pain  of  peritoneal 
extravasation.  Rigidity  of  the  abdominal  muscles  over  the  seat  of  pathology 
in  appendicitis  is  a  great  aid  to  interpreting  the  pain.  The  muscular  rigidity 
is  protective  and  due  to  the  transmission  of  the  visceral  irritation  to  the 
spinal  cord,  which  is  reflected  to  the  abdominal  skin  (sensory)  and  to 
abdominal  muscles  (motor).  There  is  a  nice  balance  between  the  peripheral 
visceral  and  the  peripheral  cutaneous  nerves  in  the  abdominal  muscles 
through  the  spinal  cord.  Local  tenderness  and  local  rigidity  of  the  abdominal 
muscles  is  a  great  aid  in  signification  of  the  sudden  acute  pain  in  append- 
icitis. It  might  be  well  to  suggest  that  the  position  of  the  appendix  is  located 
at  any  point  from  the  liver  to  the  floor  of  the  pelvis,  and  also  many  times 
where  there  is  more  or  less  of  a  mesenterium  commune,  the  cecum  may 
approach  the  vertebral  column,  and  the  appendix  is  then  liable  to  lie  among 
the  enteronic  coils — the  dangerous  ground  of  peritonitis.  It  is  likely  the 
pain  in  appendicitis  depends  on  the  seat  of  the  disease,  i.  e.,  the  mucous 
membrane  has  become  ulcerated,  inducing  painful  appendicular  colic  (peri- 
stalsis), while  the  sudden  exacerbation  of  violent  diffuse  abdominal  pain  is 
due  to  the  involving  of  the  peritoneum  itself  from  the  fecal  extravasation 
and  from  violent  peristalsis.  I  see  nothing  especially  worthy  of  attention  in 
the  so-called  McBurney  point.  It  is  skin  sensitiveness.  Pain  over  the  seat 
of  disease  is  certainly  a  natural  feature,  and  generally  so  over  the  appendix, 
which  lies  under  a  point  midway  between  the  umbilicus  and  anterior  superior 
spine  of  the  ileum.  But  it  is  not  always  so  by  any  means,  for  I  examined 
with  great  and  anxious  care,  a  short  time  ago,  a  young  physician  with  severe 
pain  over  the  so-called  McBurney  point,  when  on  operation  the  long  appendix 
was  in  the  pelvis  and  perforated.  McBurney's  point  is  practically  a  cutane- 
ous hyperesthesia.  Then  again  pain  on  pressure  may  be  reflex,  appearing  in 
remote  regions  of  the  abdomen.  The  sudden,  acute,  diffuse  abdominal  pain 
arising  in  appendicitis,  generally  subsides  in  the  right  iliac  fossa  after  thirty- 
six  hours,  and  one  can  nearly  always  elicit  pain  on  pressure  there.  This 
pain  on  pressure  is  doubtless  the  motion  radiation,  transmitted  to  a  sensitive, 
inflamed  peritoneum,  and  not  the  dragging  of  an  adhesion,  as  some  assert, 
for  adhesion  so  newly  formed  can  have  no  nerves  formed  in  them.  But  man 
is  subject  to  appendicitis  four  times  as  frequently  as  woman,  due,  perhaps 
to  Gerlach's  valve  being  small  in  man,  and  thus  not  allowing  the  foreign  body 
to  escape  after  entrance,  and  due  also  to  the  greater  activity  of  the  psoas 
muscle  in  man,  inducing  more  peritoneal  adhesions  to  compromise  the 
anatomy  and  physiology  of  the  appendix.  Contracting  adhesions  compro- 
mises appendicular  drainage.  The  appendix  lies  on  the  psoas  muscle  in 
man  more  frequently  than  in  woman,  and  on  its  longest  range  of  activity. 


SUDDEN    ABDOM/XAL    PAIX—1TS   SIGNIFICANCE 


417 


hence  when  the  appendix  contains  virulent  and  pathogenic  germs,  the  long 
range  of  action  of  the  psoas  so  traumatizes  the  appendix  that  it  induces 
the  escape  or  migration  of  the  accidental  virulent  pathogenic  microbes 
through  the  appendicular  walls  into  the  peritoneal  cavity.  Common  sense 
and  experience  would  dictate  that  the  pain  on  pressure  would  occur  in  any 
point  of  the  abdomen  possessing  inflamed  structures.  Since  probability  is 
the  rule  of  life  it  is  well  to  search  for  pain  in  the  three  great  regions  of 
dangerous  peritonitis,  viz.,  the  pelvic,  appendicular  and  gall-bladder  regions. 
In  appendicitis  the  pain  on  pressure  is  in  the  ileo-coecal  plexus,  i.  e.,  in  the 


NONDESCENDED    APPENDIX 

Fig.  102.  The  appendix  is  associated  with  the  liver.  The  appendix  (coecum)  is  nonde- 
scended  in  males  9  per  cent  and  in  females  5  per  cent.  In  this  case  there  is  an  ileo-coecal 
volvulus. 

ileo-coecal  angle,   not  at  the  so-called  McBurney's  point,  which  is  a  nerve 
skin  neurosis — a  skin  hyperesthesia. 

The  ileo-colic  plexus  may  be  found  tender  on  bi-manual  vaginal  examin- 
ation, especially  on  the  right  side.  However,  these  hyperesthetic  (tender) 
points  are  insufficient  to  establish  a  diagnosis  of  appendicitis.  Palpable 
anatomic  findings  are  the  only  reliable  data  for  the  diagnosis  of  appendicitis. 


27 


418  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

BILIARY    CHANNELS. 

The  digestive  tract  has  still  another  common  seat  for  sudden  acute 
abdominal  pain,  and  that  is  the  gall-bladder  region.  The  sudden  acute 
abdominal  pain  in  hepatic  colic  is  not  generally  so  violent  as  many  others 
accompanying  acute  diseases  of  the  digestive  tract.  Patients  relate  that  the 
pain  is  aching,  dragging,  and  in  the  active  stage  of  cutting  or  tearing.  Some 
relate  a  feeling  of  tightness  or  fullness.  But  it  depends  on  whether  the  cal- 
culus is  attempting  to  enter  constricted  portions  of  the  duct,  or  whether  it 
has  already  entered.  I  have  had  typical  cases  where  operation  proved  that 
the  calculi  only  attempted  to  enter  the  constricted  portion  of  the  duct.  Xo 
doubt  these  are  the  cases  which  say  so  often  that  they  have  severe  pains  at 
any  time,  but  especially  after  taking  hot  meals  or  hot  stimulating  drinks,  or 
vigorous  exercise;  whence  arises  excessive  peristalsis,  inducing  short,  tem- 
porary hepatic  colic.  Now,  when  the  gall-bladder  has  many  calculi  in  it, 
and  when  one  more  or  less  often  attempts  to  engage  in  the  neck  of  the  gall- 
bladder, the  pain  is  rhythmical.  It  begins  slowly  and  rises  to  a  maximum. 
At  the  maximum  the  pain  is  intense.  We  have  observed  such  cases  and  after- 
wards operated  on  them,  removing  many  small  calculi.  Gall-stone  exists 
perhaps  four  times  as  frequently  in  women  as  in  men;  why,  we  do  not  know. 
In  my  experience  patients  can  generally  locate  the  pain  in  hepatic  calculi  more 
accurately  and  definitely  than  almost  any  other  sudden  acute  abdominal  pain. 
They  refer  the  pain  to  its  proper  locality;  however,  I  must  admit  that  this 
reference  is  before  rupture.  After  rupture  of  the  cholecyst  or  duct  the  pain 
is  indefinite,  like  other  perforation  in  the  peritoneum.  The  sudden  acute 
abdominal  pain  in  biliary  duct  disease  is  characterized  by  more  slowness, 
less  acuteness,  intensity  and  distinct  periodicity,  than  in  invagination, 
appendicitis  or  perforation  of  the  digestive  tract.  Jaundice  is  not  necessary. 
Jaundice  or  icterus  is  determined  by  the  color  of  the  eye-ball,  and  not  of  the 
skin.  A  feature  in  gall-bladder  pain  is  that  it  extends  well  towards  the 
dorsum.  Age  aids  in  diagnosing  calculus  in  the  biliary  passages  to  some 
extent. 

The  patient,  frequently  middle  aged  women,  is  suddenly  seized  with 
agonizing  pain  in  the  epigastrium,  vomiting  and  occasional  collapse.  The 
pulse  rapid  and  small,  the  epigastrium  tender  (cutaneous  hyperesthesia)  and 
the  right  abdominal  muscles  rigid  (intercostal  motor  nerves  irritated,  cor- 
responding to  its  sensory  roots  of  the  spinal  cord).  With  progress  of  the 
case  the  pain  localizes  in  the  right  hypochondrium  and  peritonitis  begins. 
I  have  had  cases  of  rupture  of  the  gall-bladder  with  no  known  premonitory 
symptoms. 

It  must  be  borne  in  mind  that  gall-bladder  perforation  presents  a  differ- 
ent picture  than  merely  violent  peristalsis  (colic)  due  to  gall-stone  in  the 
biliary  passages. 

The  pain  of  non-perforated  biliary  colic  arises  suddenly,  is  agonizing,  and 
especially  intense  in  the  gall-bladder  region.  It  is  generally  limited  in  dur- 
ation, and  frequently  associated  with  jaundice.  Biliary  calculus  may  exist 
without  pain  (autopsies  are  rich  in  this  testimony). 


SUDDEN    ABDOMINAL    PAIN^ITS   SIGNIFICANCE 


419 


ACUTE    HEMORRHAGIC   PANCREATITIS. 

The  pain  in  acute  hemorrhagic  peritonitis  is  characterized  by  being  sudden, 
terrible,  agonizing  and  remains  persistent  in  the  region  of  the  pancreas.  The 
patient  is  attacked  so  violently  that  he  faints,  collapses.  The  vomitus  is  a 
greenish  fluid  contained  in  bile  and  blood.  The  patient  suffers  intensely 
in  the  epigastric  region.  It  presents  the  symptoms  of  peritoneal  extravasa- 
tion (hence  excruciating  pain),  small,  rapid  pulse,  rigid  abdomen  with 
sensitive,  tender  skin,  skin  cool  and  bedecked  with  a  clammy  perspiration. 
Temperature  ranges  high.  Pro- 
found sepsis  gradually  deepens 
and  death  supervenes  in  a  few 
days.  Acute  hemorrhagic  pan- 
creatitis is  a  rare  disease;  I  saw 
no  case  in  some  700  autopsies. 
It  is  seldom  diagnosed,  as  we 
still  possess  no  standard  differen- 
tiating symptoms.  Diabetes  is 
suggestive  of  hemorrhagic  pan- 
creatitis or  fat  necrosis. 

EMBOLUS    WITH    MESENTERIC 
VESSELS. 

Embolus  of  the  mesenteric 
vessels,  a  rare  disease,  produces 
sudden  severe  abdominal  pain.  It 
is  difficult  to  diagnose  and  is  likely 
to  be  equally  difficult  to  treat  by 
any  means  at  our  command.  The 
difficulty  will  be  in  estimating  the 
amount  of  intestinal  resection 
required  on  account  of  the  indefi- 
nite demarcation  of  the  line  of 
gangrene  due  to  the  embolus. 

URINARY   TRACT. 


BILIARY    CALCULUS    DISLODGED    FROM 
MECKEL'S   DIVERTICULUM 

Fig.  103.  This  illustration  is  from  a  woman 
physician,  death  from  peritonitis  following  ente- 
ronic  obstruction  by  a  biliary  calculus,  which 
had  become  dislodged  from  Meckel's  divertic- 
ulum. 


In  ureteral  colic  it  must  be 
said  that  the  pain  resembles  that 
of  hepatic  colic  in  many  ways, 
the  rhythm  being  paroxysmal.  It  intermits  and  is  often  agonizingly  spas- 
modic. It  requires  much  careful  study  to  differentiate  the  sudden  acute 
abdominal  pain  in  hepatic  and  ureteral  colic.  This  is  important,  for  the 
plan  of  action  is  very  different.  The  pain  in  appendicitis,  ureteral  and 
hepatic  colic  are  in  close  relation  and  resemble  each  other. 

Sudden  pain  in  the  lumbar  region,  with  progressive  radiation  toward  the 
inguinal  region,  and  especially  testicular  retractions,  is  suggestive  of 
ureteral  calculus.     The  kidney  is  frequently  tender  on  pressure.     Ureteral 


420  THE  ABDOMINAL  AND  PELVIC  BRAIN 

calculus  permits  time  to  complete  the  diagnosis,  as  it  is  non-inflammatory, 
hence  we  examine  the  urine  for  albumen,  blood  and  pus  and  with  the  X-ray 
for  shadows. 

The  perforation  of  the  ureter  will  result  in  extra-peritoneal  extravasation 
which  does  not  induce  such  excruciating  pain  as  intra-peritoneal  extra- 
vasation. 

1.  Pain  is  a  cardinal  symptom  of  ureteral  calculus. 

2.  Pain  is  not  a  sign  of  ureteral  calculus. 

3.  Pain  as  a  single  standard  is  liable  to  lead  to  erroneous  conclusions 
and  to  an  incorrect  diagnosis. 

4.  In  eighty  operations  with  pain  as  the  guiding  symptom  for  ureteral 
calculus  70  per  cent  failed  to  demonstrate  calculus. 

5.  The  vast  dimensions  of  the  plexus  nervosus  ureteris  in  number  of 
ganglia  and  number  of  strands  permit  irritation  from  the  ureter  to  pass 
with  facility  and  rapidity  to  the  abdominal  brain,  whence  it  becomes 
reorganized  and  emitted:  (1)  over  the  sympathetic  nerves  of  the  abdominal 
visceral  plexuses,  inducing  pain,  aching,  reflexes  in  the  adjacent  viscera; 
(2)  the  reorganized  irritation  in  the  abdominal  brain  is  emitted  over  the 
spinal  nerves;  (a)  the  intercostals  (pain  in  abdominal  walls);  (b)  over  the 
lumbar  plexus  (pain  in  inguinal,  hypogastric  and  external  genital  regions); 
(c)  over  the  sacral  plexus  (pain  in  the  nates,  genitals,  rectum,  thigh,  leg  and 
foot).  (3)  The  irritation  of  the  plexus  of  nerves  passes  to  the  abdominal 
brain  where  it  is  reorganized  and  emitted  over  the  cranial  nerves  (vagus  which 
aids  in  inducing  nausea  and  vomiting).  These  reflex  pains  in  ureteral  cal- 
culus confuse  by  involving  the  sympathetic,  spinal  and  cranial  nerves  of 
distant  regions,  and  also  because  other  conditions  of  the  ureters  than  ureteral 
calculus  may  duplicate  or  simulate  the  reflex  pain. 

6.  Pain  simulating  that  of  ureteral  calculus  is  a  common  symptom  of 
many  diseases  of  the  abdominal  viscera. 

7.  Ureteral  calculus  may  exist  without  pain  (post-mortems  are  rich  in 
this  testimony). 

8.  Calculus  may  exist  with  the  manifestation  of  pain  in  some  adjacent 
visceral  tract  only,  for  example,  pain  in  testicle,  or  ovary  (genitals). 

9.  Other  diseases  of  the  urinary  tract  than  ureteral  calculus  may 
simulate  or  duplicate  a  pain  (ureteritis,  malignancy,  hematuria  tuberculo- 
sis, vesical  calculus,  growth,  cystitis). 

10.  Reno-ovarian  reflex,  reno-testicular  reflex,  or  reno-uterine  reflex 
pains  are  not  signs  of  ureteral  calculus,  but  are  simply  intensified  local- 
izations of  pain  along  the  ureter,  which  may  exist  from  numerous  conditions. 

11.  Unilateral  pain,  stabbing  pain,  muscular  trauma  pain  (Jordan  Lloyd), 
stamping  muscular  pain  (Clement  Lucas),  pain  from  corporeal  trauma 
(muscular),  pain  from  the  sensitive  ureteral  proximal  isthmus  or  pelvis,  may 
arise  from  various  conditions  other  than  ureteral  calculus. 

12.  The  characteristic  of  pain  in  ureteral  calculus  is  inconstancy, 
variation  or  radiation  and  reflexion.  It  has  a  tendency  to  produce  sympa- 
thetic aching  in  other  abdominal  viscera. 


SUDDEN    ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


421 


13.  The  pain  in  ureteral  calculus  depends  chiefly  on  its  position  (ureteral 
pelvis  and  proximal  isthmus,  sensitiveness)  and  also  on  the  mobility  of  the 
calculus. 

14.  Tain  (colic)  can  arise  in  the 
ureter  from  increased  ureteral  pressure 
(calculus,  stricture,  flexion — obstruct- 
ing the  urinal  stream),  or  from  in- 
flamed ureteral  wall — ureteritis. 

15.  Ureteral-lithiasis,  cholelithi- 
asis, appendicitis,  ureteritis,  cystitis, 
nephritis,  may  produce  practically 
identical  symptoms. 

Intoxications. — Uremia  may  be 
accompanied  by  abdominal  pain,  lead 
colic,  blue  gum  line  and  occupation. 
Food  of  concentrated  nature  as  meats 
may  produce  such  concentrated  urine 
that  urination  is  accompanied  by  pain. 


Fig.  104.  Roentgen  ray  of  the  ductus  pancreaticus  and  part  of  ductus  bilis  (it  contains 
six  hepatic  calculi).  From  post-mortem  specimens.  I  to  II,  ductus  communis  choledochus, 
dilated  to  U  inch  in  diameter  and  containing  four  hepatic  calculi  (A,  B)  in  its  distal  end ;  II 
to  IV,  ductus  cysticus,  dilated  to  Yi  inch  in  diameter,  yet  preserving  in  form  six  valvulae 
Heisterii;  II  to  III,  ductus  hepaticus,  dilated  to  l/z  inch,  containing  a  hepatic  calculus ;  C, 
cholecyst,  normal  dimension,  containing  no  calculus;  P,  ductus  pancreaticus  (ductus 
Hofmanii-Wirsungii),  ductus  pancreaticus  accessorius  (ductus  Santorini).  Hepatic  calculi, 
C,  D  and  B. 


422  THE  ABDOMINAL  AND  PELVIC  BRAIN 

TRACTUS   GENITALIS. 

The  sudden  acute  abdominal  pain  arising  from  the  genitals  is  more  easily 
interpreted  and  managed.  The  pain  can  be  more  definitely  located  by  the 
patient;  and  sudden  disorganization  of  viscera,  being  accessible  in  the  pelvis, 
is  much  more  within  control  of  the  gynecologist.  The  sudden  acute  abdom- 
inal pain  from  the  genitals  is  generally  due  to  a  ruptured  ectopic  pregnancy, 
or  the  very  rare  matter  of  the  rupture  of  a  pyosalpinx  into  the  peritoneal 
cavity.  Most  of  the  pains  are  of  slower  origin  and  almost  diagnosable.  Sex 
and  the  reproductive  age  aid  in  the  interpretation  of  the  case. 

With  a  ruptured  pregnant  oviduct  the  patient  complains  of  sudden 
excruciating,  terrible  pain  which  at  first  is  generally  diffuse,  but  rapidly  local- 
izes in  the  pelvic  region.  The  sudden  pain  is  persistent,  muscular  rigidity  is 
intense,  the  abdomen  is  tender  and  the  patient's  face  is  anxious;  with  the 
impending  crisis,  vomiting  is  not  conspicuous.  If  the  hemorrhagic  peritoneal 
extravasation  is  ample  the  pain  is  excruciating,  and  faintness,  syncope,  shock 
with  extreme  anemia  occurs.     Death  frequently  occurs  from  hemorrhage. 

Lawson  Tait  used  to  advocate  that  the  oviduct  would  rupture  not  later 
than  the  fourteenth  week.  However,  it  may  rupture  or  abort  at  any  time 
previous  to  that.  To  the  experienced  gynecologist  a  bimanual  vaginal  and 
rectal  examination  reveals  in  most  cases  ample  evidence  for  an  operation. 
In  sudden  abdominal  pain,  rapid  rise  of  pulse  with  lowering  of  temperature 
indicates  (hemorrhage)  gravity  and  demands  surgical  intervention.  It  may 
be  stated  that  during  a  decade  of  attendance  in  the  Mary  Thompson  Hospital 
for  women  and  children  Dr.  Lucy  Waite  and  myself  have  operated  on 
considerable  numbers  of  ruptured  gestating  oviducts  in  which  the  patient 
could  not  furnish  a  clinical  history  of  very  much  pain  or  exact  date  of  rupture. 

PYOSALPINX. 

In  pyosalpinx  the  pain  may  be  sudden  and  excruciating  (involving  the 
peritoneum). 

The  patient  enforces  upon  herself  extreme  physical  quietness,  breathing 
with  the  proximal  end  of  the  abdomen  only.  The  thighs  are  flexed,  the  face 
flushed,  the  abdomen  tender,  sensitive  and  rigid,  the  expression  that  of  an 
impending  crisis.  Bimanual  vaginal  examination  reveals  a  large  uneven 
mass,  which  is  excruciatingly  painful. 

The  mass  should  be  palpated  gently  for  fear  of  rupture.  One  of  my 
patients  with  a  very  large  pyosalpinx  strained  at  stool,  causing  rupture  and 
death  from  peritonitis.  At  the  autopsy  I  found  perhaps  a  quart  of  pus,  free 
in  the  peritoneal  cavity.  She  died  from  excruciating  pain  and  shock  in  some 
ten  hours. 

In  regard  to  the  character  of  sudden  abdominal  pain  arising  from  the 
genitalis  is  more  easily  interpreted  and  managed.  The  pain  can  be  more 
definitely  located  by  the  patient;  and  similar  to  other  sudden  acute  abdom- 
inal pain,  it  varies  as  to  its  mode  of  attack,  and  as  to  viscera  affected. 

The  pain  of  pyosalpinx  is  generally  that  of  a  local  peritonitis;  however., 
it  is  limited  in  its  reflexion  to  other  peritoneal  areas. 


SUDDEN   ABDOMINAL   PAIN— ITS   SIGNIFICANCE 


423 


AXIAL  TORSION   OF   PEDICLES   OR   VISCERA. 

Torsion  of  style  or  rotation  of  pedicle  of  a  viscus  is  characterized  by 
sudden  severe  abdominal  pain.  The  intensity  of  the  pain  depends  on  the 
completeness  of  the  constriction  in  the  pedicle. 

The  tumor  rotated  on  its  axis  gradually  enlarges  because  the  venous 
blood  cannot  return,  while  the  arterial  blood  continues  to  pass  into  the 
tumor.  Ovarian  tumors  rotate  on  their  axes  or  pedicles  perhaps  the  most 
frequently  subsequent  to  parturition.  The  initial  pain  is  generally  severe 
but  not  excruciating  like  extravasation  in  the  peritoneal  cavity.     As  usual 


Fig.  105.  Specimen  containing  pancreatic  calculus.  From  a  post-mortem ;  man  about 
40  years.  I  to  II,  ductus  choledochus  ;  II  to  III,  ductus  hepaticus  ;  III  to  IV,  ductus  cysticus  ; 
Sa,  ductus  pancreaticus  accessorius ;  P,  separate  exit  of  ductus  pancreaticus  in  duodenum. 
A  calculus  }i  inch  in  length  and  l/d  inch  in  diameter  is  incarcerated  in  the  duct  of  the  caput 
pancreaticum.  The  calculus  of  the  pancreatic  duct  projects  into  the  lumen  of  the  duodenum. 
Also  six  calculi  existed  in  the  ductus  pancreaticus,  as  noted  in  sketch.  The  pancreas  was 
in  an  advanced  stage  of  suppuration  and  fatty  degeneration.  This  specimen  was  kindly  pre- 
sented to  me  by  Dr.  A.  M.  Stober.  B.  J.  Beuker  sketched  it  from  the  pathologic,  laboratory 
of  Cook  County  Hospital. 

the  pain  is  first  diffuse,  and  later  becomes  localized  in  the  region  of  the 
increasing  tumor  from  accumulating  venous  blood  and  nerve  trauma. 

Hyper-rigidity  of  abdominal  muscles  and  hyperesthesia  of  abdominal 
skin  accompanies,  exists  (on  account  of  reflex  irritation  in  the  spinal  cord). 

One  of  the  most  important  aids  to  diagnosis  is  that  the  women  possess 
a  tumor,  and  that  with  accompanying  abdominal  pain  the  tumor  gradually 
enlarges  because  the  rotating  pedicle  easily  constricts  the  thin  walled  veins, 
while  the  rigid  walled  artery  persists  in  injecting  its  continuous  stream  into 
the  tumor. 

I  have  witnessed   torsion  of  pedicles  in  ovarian  tumors,  oviduct  sigmoid, 


[24  THE  ABDOMINAL  AXD  PELVIC  BRAIX 

ileocecal  apparatus,  myoma,  enteron,  omentum  and  kidney.  Torsion  of 
pedicles  may  apply  to  tubular  viscera  (ureter,  intestine,  oviduct  J  as  well 
as  to  vessels. 

I  have  operated  on  subjects  with  myomata  rotated  to  such  an  extent  that 
the  entire  original  blood  supply  was  completely  obliterated,  the  tumor  being 
nourished  by  newly  formed  blood  vessels  from  adjacent  viscera,  especially 
from  the  omentum  majus.  Rokitansky  of  Vienna,  first  called  attention  to 
the  axial  rotation  of  tumors  some  forty  years  ago. 

The  facility  of  pedicular  torsion  depends  on  the  elongation  and  limited 
dimension  of  the  pedicles.  Volvulus  is  but  axial  torsion  facilitated  in  the 
sigmoid  by  a  narrow  foot  or  base  (due  mainly  to  mesosigmoiditisj. 

Axial  torsion  of  the  digestive  tract  constitutes  about  one-fortieth  of 
intestinal  obstruction.  Perhaps  6  per  cent  of  ovarian  and  parovarian  tumors 
experience  axial  torsion.  Mr.  Lawson  Tait  saw  some  70  cases,  and  as  his 
pupil  I  witnessed  with  admiration  his  amazing  acumen  in  diagnosing  and 
successfully  operating  on  axial  rotated  tumors.  My  assistant,  Dr.  A.  Zetlitz, 
operated  on  a  patient  with  almost  complete  torsion  of  the  uterus,  and 
examining  the  specimen  evidence  demonstrated  itself  that  it  was  a  slow 
chronic  process  and  closely  associated  with  peristalsis. 

Axial  torsion  of  viscera  may  be  acute  or  chronic,  complete  (pathologic) 
or  incomplete  (physiologic),  hence  the  manifestations  of  pain  will  vary. 

Axial  torsion  of  abdominal  viscera  (tumorsj  are  no  doubt  rotated  by  the 
peristalsis  of  the  viscus  itself  or  that  of  adjacent  viscera,  especially  the  colon 
(sigmoid),  which  by  its  rhythmic  movements  rotates  the  ovarian  tumor,  the 
omentum  and  the  ilium  about  the  cecum.  Tumors  with  axial  torsions  should 
be  at  once  removed,  while  vital  viscera  with  axial  torsion  should  be  reduced, 
untwisted,  detorsioned,  and  sutured  in  situ,  for  axial  torsion  tends  to  recur. 
It  may  be  due  to  the  constriction,  to  the  blood  vessels,  to  the  peristalsis  or 
adjacent  peritonitis. 

CHIEF    FACTORS    INVOLVED    IN    SUDDEN    ABDOMINAL   PAIN. 

The  accompanying  table  presents  a  bird's-eye  view  of  some  of  the 
practical  factors  involved  in  sudden  abdominal  pain.  Indelible  opinions  must 
be  entertained  in  the  diagnosis  as  to  the  signification  of  the  abdominal  pain, 
whether  it  be  from  peritonitis  (septic  lesion  from  adjacent  viscera),  or  pain 
from  violent  peristalsis  (colic),  or  tubular  viscera  (due  to  mechanical  irrita- 
tion, calculus,  stricture,  flexion  or  from  inflamed  parietes).  For  practical 
purposes  I  will  present  a  skeletal  table  of  sudden  pain  of  the  six  visceral 
tracts,  intestinal,  urinary,  vascular,  lymphatic,  nervous,  and  genital.  It  is 
evident  that  abdominal  pain  rests  on  common  factors,  as  (a)  flexion ;  (b) 
stricture;  (c)  calculus  (violent  peristalsis,  colic)  of  tubular  viscera,  in  which 
the  danger  and  pain  are  limited.  Perforation  (extravasation  into  the  perito- 
neum) of  tubular  viscera  in  which  danger  and  pain  are  unbounded.  A  decade 
ago  it  was  thought  sufficient  to  remember  the  three  dangerous  peritonitis 
regions,  viz.,  pelvic,  appendicular,  and  gall-bladder.  With  the  present 
accumulated  knowledge  of  the  abdominal  viscera  the  field  presents  problems 


SUDDEN    ABDOMINAL    PAIN— ITS    SIGNIFICANCE 


425 


of  increasing    complexity  as  presented  in  the  following   bird's-eye  view    of 
numerous  causes  of  abdominal  pain  in  the  several  visceral  tracts: 


Gastrium,  enteron,  append- 
ix, colon 
Biliary  ducts 
Pancreatic  duct 


I.    Tractus  Intestinaus    \ 


4.     Volvulus 

.r).     Strangulation 

6.     Invagination 


flexion 

stricture 

calculus 

inflammation 

perforation 

neoplasm 

colic 

sigmoid  60  per  cent 

ileocecal  apparatus  30  per  cent 

enteron  10  per  cent 
j  bands 
/  apertures 

ileocecal  apparatus  70  per  cent 

enteron  15  per  cent 

colon  15  per  cent 


Ulceration  (gastrium,  enteron,  colon) 
Splanchnoptosia 


(Appendages) 


(a)    Liver 


(b)    Pancreas 


(a)  ducts — calculus,  inflamma- 
tion, neoplasm 

(b)  parenchyma,  hepatitis,   ne- 
oplasm 

(c)  ducts — calculus,  inflamma- 
tion, neoplasm,  pancreatitis 

(d)  parenchyma — necrosis,  ne- 
oplasm 


II.     Tractus  Urinarius 


III.     Tractus  Genitalis 


f1- 

u 


Spleen — splenitis,  neoplasm 
Ureter 


Bladder 
Prostatitis- 


f  1.     Oviduct 


\ 


2.     Ovarv 


3.     Uterus 


IV. 


r  Veins — phlebitis,  thrombosis 
Tractus  Vascularis  <  Artery — embolus 
'k  Artery — aneurism 

{peritoneum — peritonitis 
glands — adenitis 
ducts — lymphangitis 
'  pain — constant,  periodic 
pain — on  pressure 
neuritis 
neuroma 
neuralgia 
,  hyperesthesia 


flexure,  stricture,  calculus,  in- 
]    flammation,  perforation,  colic 

(  calculus,  inflammation,  perfor- 

(    ation,  colic 
vesiculitis  seminales. 

perforation,  abortion,  colic,  in- 
flammation, torsion,  neo- 
plasm 

\  perforation,  inflammation,  tor- 

(      sion,  neoplasm 

{perforation,  abortion  inflam- 
mation, colic,  torsion,  neo- 
plasm 


VI.     Tractus  Nervosus 


CONCLUSIONS    AS    REGARDS    SUDDEN    ABDOMINAL   PAIN. 

I.  There  are  three  kinds  of  sudden  abdominal  pain,  viz. :  (a)  that  of 
peritonitis,  perforation,  inflammatory,  septic  lesions  from  adjacent  visceral 
peritoneal  extravasation,  continuous  excruciating  pain  (pain  continuous, 
unlimited  and  life  in  jeopardy),  as  1,  perforation    of  the  tractus   intestinalis 


426 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


(gastrium,  enteron, 
channels). 

2.  Perforation 
hydrosalpinx,  uterus 

3.  Perforation 

4.  Perforation 
chyle  channels). 

5.  Perforation 
embolus,  oviductal 
urinarius,    genitalis, 
or  extraperitoneal. 


colon,   appendix — its  appendages,   biliary  or  pancreatic 

of  the  tractus  genitalis  (oviductal  gestation,  pyosalpinx, 

,  ovary). 

of  the  tractus  urinarius  (kidney,  ureter,  bladder). 

of    the    tractus    lymphaticus  (chyle  duct,    chyle    cysts, 

of  the  tractus  vascularis  (aneurism,  hemorrhage, 
gestation,  is  hemorrhage).  (The  tractus  intestinalis, 
vascularis,  lymphaticus  may  perforate,  intraperitoneal 
In    extraperitoneal    perforation,  the  pain  is  similar  to 


HEPATIC  CALCULUS  IN  HARTMAN'S  POUCH  (S)  AND  VATER'S  PAPILLA 

Fig.  106.  Presents  hepatic  calculus  in  the  usual  locations,  Hartman's  pouch  and  Vater's 
diverticulum.  A  calculus  in  Vater's  pouch  aids  to  obstruct  and  infect  the  ductus  pancreati- 
cus. 


intraperitoneal  perforation  except  in  degree,  however,  the  danger  of  the 
extraperitoneal  visceral  perforation  is  limited) ;  (b)  that  of  violent  peristalsis 
(colic,  non-inflammatory)  of  tubular  viscera,  as  in  mechanical  irritation, 
calculus,  stricture,  obstruction,  volvulus,  flexion,  oviductal  gestation,  par- 
turition, constipation,  aneurism,  invagination,  hernia,  strangulation  by  band 
(inflammatory),  (pain  limited,  periodic,  life  not  in  jeopardy);  (c)  that  from 
painful  peristalsis  (colic  inflammatory)  from  inflamed  parietes  of  tubular 
viscera,  as  ureteritis,  choledochitis,  salpingitis,  cholecystitis,  cystitis, 
myometritis,  myocorditis,  enteritis,  colitis,  appendicitis  (pain,  periodic, 
inflammatory,  life  not  in  jeopardy).  First  and  foremost  for  practical  pur- 
poses it  will  be  instructive  to  consider  sudden  abdominal  pain  from  perfora- 
tion of  the  three  excretory  mucous  visceral  tracts,  viz. :  intestinal,  genital  and 


SUDDEN   ABDOMLXAL   PAIN— ITS   SIGNIFICANCE  427 

urinary  (as  they  not  only  perforate  but  develop  immediate  sepsis  and 
jeopardize  life).  Second,  sudden  abdominal  pain  should  be  considered 
from  perforation  of  the  two  non-excretory,  non-mucous  visceral  tracts,  viz., 
vascular  and  lymphatic  (as  they  perforate,  but  do  not  develop  immediate 
sepsis  nor  place  life  in  immediate  danger). 


Fig.  107.  Carcinoma  completely  obstructing  the  biliary  and  pancreatic  ducts.  Illustrates 
an  x-ray  of  enormously  dilated  biliary  passages.  The  biliary  ducts  (excepting  the  gall- 
bladder, which  was  three  to  four  times  its  normal  dimension)  had  a  capacity  of  32  ounces, 
about  six  or  seven  times  the  natural  capacity.  The  ductus  communis  choledochus  was  over 
1%  inches  in  diameter.  The  pancreatic  duct  admitted  the  index  finger.  The  man,  69  years 
old,  a  giant  in  stature,  weighing  some  250  pounds  with  ordinary  limited  fat,  lost  115  pounds 
in  weight  during  three  months'  illness.  The  ductus  cysticus,  extending  from  II  to  IV,  had 
seven  Heister's  valves,  and  its  lumen  would  admit  a  lead-pencil  only.  At  B  the  biliary  ducts 
were  deficient  within  the  liver  substance,  but  were  really  dilated  on  the  surface.  T,  the 
carcinoma  (divided  with  the  scalpel),  completely  severing  the  lumen  of  the  biliary  and  pan- 
creatic ducts.  There  was  enormous  gastroduodenal  dilatation  from  the  compression  of  the 
transverse  duodenum  by  the  superior  mesenteric  artery  (A)  and  vein  (V).  D,  foldless,  gran- 
ular, proximal  2l/2  inches  of  the  duodenal  mucosa ;  I,  entrance  of  ductus  communis  chole- 
dochus in  the  duodenum;  Sa,  ductus  Santorini;  P,  ductus  pancreaticus.  The  ductus 
communis  choledochus  and  ductus  pancreaticus,  located  between  the  carcinoma  and  Vater's 
diverticulum,  were  normal.  Da,  is  the  normal  sized  duodenum  located  distal  to  the  com- 
pressing superior  mesenteric  vein  (V)  and  artery  (A).  Observe  the  vast  dilatation  of  the 
duodenum  proximal  to  the  superior  mesenteric  artery  (A)  and  vein  (V).  I  secured  this  rare 
specimen  at  an  autopsy  through  the  courtesy  of  Dr.  Charles  O'Byrne. 


428 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


II.  In  making  a  diagnosis  of  sudden  abdominal  (constant)  pain 
probability  is  the  rule  of  life,  e.  g.,  (a)  sudden  abdominal  (constant) 
pain  accompanied  with  vomiting,  abdominal  rigidity,  rise  of  pulse  and 
temperature,  tympanitis,  is  peritonitis  (perforative),  as  appendicular,  geni- 
tal, biliary,  gastro-intestinal,  hemorrhagic  pancreatitis,  (b)  sudden  (incon- 
stant) abdominal  pain  with  practi- 
cally negative  pulse  temperature, 
abdominal  rigidity,  tympanitis  and 
perhaps  vomiting,  is  violent  peri- 
stalsis (colic),  as  flexion,  stricture, 
calculus,  inflammation,  strangula- 
tion, invagination,  volvulus,  axial 
torsion. 

III.  Extravasation  in  the  peri- 
toneal cavity  is  accompanied  by  ago- 
nizing, excruciating  pain. 

IV.  The  leading  symptoms 
should  not  be  obscured  by  opiates 
until  its  complete  clinical  history  as 
nearly  as  possible  is  obtained. 

V.  The  clinical  history  is  fre- 
quently a  pencil  of  light  in  the 
diagnosis  of  sudden  abdominal  pain. 

VI.  Examine  the  patient  com- 
pletely from  head  to  foot  (especially 
per  rectum  and  per  vaginum). 

VII.  Exploratory  peritonoto- 
my  is  chiefly  justified  only  in 
ascertaining  the  extent  of  visceral 
diseases  and  rarely  justified  to  deter- 

vy^'  mine  a  diagnosis. 

VIII.  Delay  in  deciding  the 
diagnosis  of  sudden  severe  abdom- 
inal pain  should  be  avoided. 
Prompt  diagnosis  is  the  sheet  an- 
chor for  immediate  successful  med- 
ical or  surgical  treatment. 

IX.  It  must  be  remembered 
that  sudden  severe  abdominal  pain 
is  a  matter  of  gravity,  and  prompt 
investigation  with  prompt  decisions 

should  occur  so  that  the  patient's  life  may  not  be  placed   in    jeopardy  by 
delay,  or  disastrous  treatment  be  instituted. 

X.  (a)  Determine,  if  possible,  the  location  of  the  initial  pain;  (b) 
inquire  if  the  pain  was  at  first  diffuse  in  the  central  abdomen  for  awhile; 
(c)  later  and  final  observe  whether  the  pain  localizes  itself  in  the  region  of 
the  affected  organ  (peritonitis). 


URETERAL   CALCULI 

Fig.  108.  This  illustrates  uretera.  calculus 
in  its  usual  location,  viz.,  (a)  in  the  ureteral 
pelvis  at  the  proximal  isthmus  (w),  (b)  in  the 
pelvic  ureter  at  P. 


SUDDEN    ABDOMINAL    PAIN— ITS   SIGNIFICANCE 


429 


XI.  The  location  of  the  pain  may  be  superficial  (hyperesthesia  of  the 
skin)  or  deep  in  the  muscularis  (rigidity).  McBurney's  point  is  a  skin 
hyperesthesia  (from  the  cutaneous  branches  of  the  twelfth  dorsal  and  first 
lumbar  nerve — ileo-hypogastric). 

XII.  The  location  of  sudden  abdominal  pain  is  indicated  by  the  segment 
(somatic)  of  the  spinal  nerves  in  adjacent  abdominal  muscles  (rigidity),  skin 
(hyperesthesia).  The  diseased  abdominal  viscus  is  protected,  fixed  by 
muscular  and  nerve  mechanism  similar  to  the  muscular  protection  fixation  of 
an  inflamed  joint. 

XIII.  The  topographic  anatomy  of  the  abdominal  viscera  should  be 
mastered,   for,   it    is  the   solid    ground 

of  nature  on  which  rests  rational  diag- 
nosis. This  can  be  accomplished  by 
study  in  the  cadaver  and  at  autopsy. 

XIV.  Remember  the  major 
regions  of  peritonitis — appendicular, 
pelvic  and  that  of  the  gall-bladder. 

XV.  Remember  the  major  re- 
gions of  violent  peristalsis,  colic  (cal- 
culus), biliary,  ureteral,  oviductal  and 
pancreatic. 

XVI.  Call  the  most  available  and 
competent  abdominal  surgeon  early  in 
consultation. 

XVII.  Remember  that  operations 
do  not  kill — it  is  disease  that  tolls 
the  funeral  bell. 

XVIII.  Operations  on  the  dying 
are  unsatisfactory. 

XIX.  As  a  general  idea  it  may 
be  stated  that  it  is  difficult  to  deter- 
mine with  precision  the  cause  of 
sudden  abdominal  pain.  One  must 
frequently  ask  Jupiter  to  guide  them 
in  the  greatest  field  of  probability  (ap- 
pendicitis, salpingitis,  chole  cystitis). 

The  operator  who  performs  peritonotomy  for  abdominal  pain  should  be 
prepared  for  any  emergency  for  the  toxion  of  pain  within  the  abdomen 
sounds  an  alarm,  the  course  of  which  can  not  with  certainty  be  determined 
externally.  One  can  not  determine  the  kind  of  wood  that  lies  under  a  table 
cloth. 

XX.  Abdominal  pain  as  a  single  symptom  is  frequently  delusive. 

XXI.  The  more  accurate  the  diagnosis  in  sudden  abdominal  pain  the 
less  "neuroses,"  "neuralgia"  or  "indigestion"  will  occur. 

XXII.  A  last  resort  to  diagnose  sudden  abdominal  pain  is  the  "explo- 
ratory and  confirmatory  incision"  of  Lawson  Tait. 


CALCULUS  IN  URETER 

Fig.  109.  Calculus  at  3  which  I  re- 
moved in  1898  and  in  1906  I  removed  a  cal- 
culus from  the  same  (left)  kidney  which 
was  atrophied  to  one-third  of  its  normal 
dimensions.  Patient  is,  six  months  after 
the  second  operation,  well. 


430 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


GENERAL  TREATMENT  OF  SUDDEN  ABDOMINAL  PAIN. 

First  and  foremost,  should  be  introduced:  (a)  anatomic  rest,  which  is 
maximum  quietude  of  skeletal  or  voluntary  muscles.  Retire  to  bed  not  to 
rise  for  defecation  or  urination;  (b)  physiologic  rest,  which  is  minimum 
function  of  viscera.     Food  and  fluid  are  prohibited  per  mouth. 


Fig.  110.     The  arteria  uterina  ovarica  3  hours  subsequent  to  parturition  at  term.     Every 
branch  of  the  artery  is  ensheathed  by  a  fenestrated  plexus  of  nerves. 

No  anodynes  or  in  minimum  repeated  doses  until  clinical  history  and 
the  diagnosis  is  completed  (maximum  doses  of  anodynes  obscure  the 
diagnosis). 

[Note — The  method  of  treatment  for  abdominal  pain  by  anatomic  and 
physiologic  rest  was  especially  advocated  by  the  distinguished  English 
physician,   Wilkes,   in  1865  (living  at  present),  continued  by  the  celebrated 


SUDDEN    ABDOMINAL    1'. UN— ITS   SIGNIFICANCE  -131 

American,  Alonzo  Clark  (1R07-1^7),  by  the  "opium  splint,"  and  established 
forever  in  1888  by  one  of  the  greatest  surgical  geniuses  of  his  age — Lawson 
Tait  (1845-1900]. 

Heat  (hot,  moist  cornmeal  poultice,  hot  water  bag,  hot  bath)  aids  to 
relieve  pain. 

No  cathartics — cathartics  stimulate  peristalsis,  increases  pain  and  dis- 
tribution of  sepsis.  They  induce  vomiting.  A  rectal  enema  (or  two)  may  be 
employed — the  composition  may  be  equal  parts  of  molasses  and  milk,  soap 
suds,  glycerine,  magnesium  sulphate.     Rectal  injections  of  air. 

BIBLIOGRAPHY. 

John  B.  Deaver  E.  S.  Ricketts  E.  Babler 

J.  H.  Musser  E.  O.  Smith  E.  Harlan 


CHAPTER  XXXII. 
GENERAL  PATHOLOGIC  PHYSIOLOGY. 

Hopeful  men  worship  the  rising,  pessimists  the  setting,  sun. 
Bumping  one's  head  against  the  universe  makes  brains. 

The  subject  of  this  paper  is  pathologic  physiology.  The  theme  is  the 
abnormal  function  of  organs,  or  organs  acting  under  pathologic  conditions. 
The  field  included  lies  between  normal  physiology  and  pathologic  anatomy. 
It  is  the  zone  of  pathologic  physiology  or  clinical  pathology.  In  general  it 
is  determined  with  facility  whether  the  visceral  functions  are  pursuing  a 
normal  or  abnormal  course.  In  certain  subjects,  however,  it  is  difficult  to 
determine  whether  the  functions  are  normal  or  abnormal.  Some  subjects 
present  unmistakable  pathologic  symptoms  for  years,  e.  g.,  constipation, 
dirrahea,  renal  secretion,  sweating;  however,  such  subjects,  though  not 
theoretically,  they  are  practically  well.  Pathologic  physiology  enables  the 
physician  to  estimate  between  theoretical  and  practical  functions.  Not 
infrequently  the  functions  of  a  subject  vary  to  such  a  degree  that  it  is  difficult 
to  decide  whether  he  is  well  or  ill.  I  know  one  subject  who,  between  forty- 
five  and  sixty  years  of  age,  would  periodically  (several  times  annually)  urinate 
some  five  quarts  daily,  otherwise  he  was  practically  well.  He  died  of  an 
acute  attack  of  diarrhea  at  seventy. 

To  understand  pathologic  physiology  one  must  possess  a  clear  view  of 
physiology.  It  may  be  well  to  remember  that  the  common  function  of  the 
thoracic  and  abdominal  visceral  tracts  are  sensation,  peristalsis,  absorption, 
secretion.  Disease  is  a  deviation  from  one  or  all  these  common  functions. 
Disease  begins  as  abnormal  function  and  progresses  with  its  repetition.  The 
study  of  pathologic  physiology  constitutes  the  subject  of  abnormal  function. 
To  the  four  common  functions  mentioned  of  the  thoracic  and  abdominal 
visceral  tracts  we  must  add  the  three  special  functions  of  the  tractus  genitalis 
— viz.,  ovulation,  menstruation,  and  gestation — which  offer  vast  fields  of 
pathologic  physiology  in  daily  practice. 

Pathologic  physiology  arises  from  defects  in  the  living  protoplasm 
(inferior  anatomy  and  physiology)  or  from  environments  (bacteria).  The 
subject  born  with  pathologic  physiology  (heredity,  stigma)  is  unable  to  with- 
stand the  friction  of  normal  life.  The  subject  may  occupy  such  environ- 
ments that  injurious  influences  affect  his  protoplasm,  such  as  excessive 
physical  or  mental  exercise,  heat,  cold,  bacteria.  The  study  of  pathologic 
physiology  dignifies  the  basic  study  of  physiology;  it  impresses  the  student 
with  the  functions  and  the  structure  of  viscera.  First  and  foremost,  the 
physiology  of  an  organ  must  be  studied  in  order  that  its  deviations  may  be 
comprehended.     The    study  of  physiology  of  organs  will  assist  in  compre- 

4i^ 


GENERAL  PATHOLOGIC  PHYSIOLOGY  433 

hending  the  factors  which  influence  the  functional  deviations.  The  subject 
of  visceral  peristalsis,  rhythmical  movements,  the  object  of  which  is  to  propel 
visceral  contents — urine,  blood,  ingesta,  lymph,  gestation  products,  secret- 
ions, carbonic  acid  gas — is  of  vast  practical  interest  in  the  daily  practice  of 
medicine.  Viscera  are  continually  being  subject  to  peristaltic  waves.  Peri- 
stalsis is  dependent  largely  on  visceral  contents  and  blood  supply.  Hence 
the  sluggish  bowels  (deficient  peristalsis)  are  improved  by  supplying  constant 
fresh  blood.  Fresh  blood  constantly  streaming  through  the  tractus  intesti- 
nalis,  urinarius,  and  genitalis  initiates  repeated  peristaltic  waves.  The  gravid 
uterus  is  in  constant  myometrial  waves  from  extra  blood  supply.  The 
tractus  intestinalis,  as  the  fresh  blood  streams  into  its  territory,  is  subject  to 
constantly  repeating  peristaltic  waves.  In  visceral  peristalsis  the  quantity 
of  blood  bathing  the  automatic  visceral  ganglia  plays  a  role. 

Since  pathologic  physiology  is  the  zone  between  physiology  and 
pathologic  anatomy  it  is  doubtless  the  incipient  stage  of  future  disease, 
pathologic  anatomy.  For  example,  chlorosis  appears  to  be  a  precursory 
stage,  a  stage  of  pathologic  physiology,  to  splanchnoptosia;  gravidity 
precedes  splanchnoptosia.  The  study  of  pathologic  physiology  cultivates 
accurate  diagnosis  in  incipient  stages  of  disease,  enhancing  opportunities 
for  prophylactic  measures.  Modern  investigation  has  forced  us  to  accentuate 
functional  (incipient)  aspect  of  disease.  It  stimulates  us  to  discover  and 
recognize  abnormality  of  function.  It  is  returning  to  physiology  as  basic 
study.  The  discovery  of  an  abnormal  function  may  lead  to  the  diagnosis  of 
a  contingent  disease.  The  disordered  function  in  the  irritable  weakness  of 
the  nervous  system  presents  inferior  anatomy  and  physiology. 

Pathologic  physiology  attempts  to  instruct  through  disordered  func- 
tions of  the  living  subject.  Pathologic  anatomy  attempts  to  instruct 
through  changed  structure  in  the  living  and  dead  subject.  In  practice, 
recognized  disordered  functions,  or  pathologic  physiology,  are  manifest 
a  hundred  fold  more  than  recognized  pathologic  anatomy.  The  old 
physicians  recognized  pathologic  physiology  under  another  name,  as 
clinical  pathology,  functional  or  sympathetic  disease.  Among  the  first  to 
discuss  pathologic  physiology  from  a  scientific  or  systematic  standpoint 
was  Cohnheim,  as  found  in  his  celebrated  general  pathology.  However, 
before  me  lies  the  third  edition  (1904)  of  Dr.  Rudolph  Krehl's  book,  the  first 
edition  of  which  (1898)  presented  a  systematic  treatise  on  pathologic 
physiology.  Practically  Dr.  Krehl's  book  is  a  pioneer  work  on  pathologic 
physiology,  systematizing  the  labors  of  Cohnheim  and  others,  as  well  as 
making  vast  additions  to  the  field  himself.  Pathologic  physiology  is  not 
a  new  subject,  for  physicians  recognized  its  existence  in  the  past.  Modern 
laboratory  methods  have  demonstrated  that  the  normal  functions  of  indi- 
vidual organs  vary  within  an  extensive  range.  The  border  line  between 
physiology  and  pathologic  physiology  is  manifest  by  symptoms  of  various 
characteristics.  Frequently  organs  will  vary  double  their  usual  range,  as  the 
quantity  of  urine  may  be  two  or  four  pints  daily,  defecation  may  be  once 
or  twice  daily,  or  every    second    day.     Perspiration  may  be  doubled  for  a 

28 


434  THE  ABDOMLXAL  AXD  PELVIC  BRAIN 

period.  We  may  observe  the  heart  beat  120  per  minute  for  weeks  with  no 
recognizable  pathologic  anatomy. 

Pathologic  physiology  is  characterized  by  an  abnormal  course  of  the 
life  of  an  organ  or  a  series  of  organs.  In  what  does  normal  course  of  organs 
consist?  We  may  designate  as  normal  living  processes  what  is  found  in  the 
vast  majority  of  individuals,  in  man  and  animals,  when  the  individuals  are 
considered  healthy.  It  is  granted  that  the  function  of  an  organ  has  normally 
an  extensive  range  of  healthy  action.  For  example,  the  quantity  of  uric 
acid  in  the  urine  of  the  genera  of  aves,  carnivora,  herbivora,  and  bimana  is 
extreme!}'  variable. 

Perhaps  man  would  not  long  survive  producing  a  quantity  of  uric  acid 
which  birds  habitually  secrete.  Each  genera  and,  perhaps,  species,  have  a 
law  for  themselves  as  regards  the  function  of  organs,  possessing  extensive 
variation  of  organ  functions,  without  being  pathologic.  Pathologic 
physiology  should  be  taught  with  more  exactness  in  the  colleges,  so  that  the 
graduates  may  not  be  compelled  to  learn  it  at  the  expense  of  their  patients. 
Pathologic  physiology  should  be  comprehensively  explained  to  students,  as 
it  enables  them  to  secure  a  general  view  of  organized  viscera,  as  well  as  the 
vicarious  action  of  individual  viscera.  Besides  it  aids  the  practitioner  to 
diagnosticate  disease  when  no  pathologic  anatomy  demonstrably  exists. 
Pathologic  physiology  is  the  zone  between  physiology  and  pathologic 
anatomy,  an  indeterminate,  extensive,  and  frequently  rapidly  varying  zone. 
It  is  well  to  bear  in  mind  that  I  am  discussing  pathologic  physiology  as 
dominated  by  the  sympathetic  nerve  (nervus  vasomotorius).  I  will  present 
in  this  essay  some  views  on  pathologic  physiology  of  the  viscera  which  I 
have  taught  for  years  in  gynecological  and  abdominal  courses. 

No  richer  f eld  exists  in  medicine,  in  inductive  research,  or  for  pro- 
ductive scholarship  than  the  establishing  of  evident  cause  and  effect  in 
patholog'c  physiology.  Pathologic  physiology  projects  physiology  into  the 
field  and  function  of  philosophy.  Physiology  is  the  most  noble  of  medical 
studies.  Science  collects  facts  while  philosophy  arranges  and  predicates  laws 
from  them.  The  field  and  function  of  philosophy  is  to  deal  with  all  classes 
and  departments  of  incomplete  knowledge  for  the  purpose  of  utilizing  it  for 
man — to  prolong  life,  lessen  suffering,  and  increase  happiness.  Pathologic 
physiology  will  aid  in  the  partial  reduction  of  medical  practice  to  laboratory 
investigation,  e.  g.,  senitlty,  local  and  general,  is  heralded  by  observable 
cellular  change — development,  differentiation  and  degeneration  of  its  vital, 
physiologic,  process.  The  ceil  is  accompanied  by  a  cyclic  series  of  changes 
from  embryoism  through  differentiation  to  senescence  termed  by  Prof. 
Minot,  cytomorphosis.  (1)  The  first  stage  or  embryonic  cell  is  peculiar  to 
itself  in  its  physiology  and  if  prolonged  by  circumscribed  inclusions  may 
become  malignantly  degenerated  in  the  adult.  (2)  The  second  stage  of. life's 
cells,  that  of  differentiation,  consists  of  two  states:  (a)  cytostatic  differen- 
tiation, or  the  production  of  a  material  of  definite  and  stable  composition,  as 
connective  tissue,  intercellular  osseous  substance— connective  tissue  frame- 
work; (b)  cytodynamic  differentiation  is  the  production  of  substance  having 


GENERAL  PATHOLOGIC  PHYSIOLOGY  435 

a  metabolic  function— parenchyma.  (3)  The  third  stage  of  life's  cell  is  that 
of  degeneration — senescence.  Hence  the  laboratory  investigator  may  yet 
discern  the  cause  that  determines  cellular  changes — embryonic,  differentiation 
and  degeneration  (senescence),  i.  e.,  the  pathologic  physiology  of  life's 
cyclic  cell  and  also  that  of  disease.  The  philosophy  of  physiology  at  once 
suggests  that  the  vital  processes  of  cells — embryologic,  differentiative, 
degenerative — cannot  be  abolished,  however,  they  can  be  advantageously 
modified.  The  destiny  of  the  cell  is  an  aggregative  mould  into  organs — for 
physiologic  function.  The  composite  organs  functionating  as  a  unit  make 
man — the  animal. 

Physiology  or  function  precedes  and  dominates  structure.  Man— the 
animal — is  the  drama,  the  play.  It  calls  into  being,  function,  the  stage 
accoutrements,  and  dramatis  personam  which  exist  and  have  signification  to 
subserve  the  drama.  The  play  selects  and  arranges  the  scenery,  creates  and 
determines  the  settings,  lends  coherence  and  sense  to  the  sentence,  furnishes 
inspiration  and  purpose  to  the  actors.  Now,  it  may  be  true  in  the  material 
presentation  of  the  play  that  stage  furniture  is  the  first  structure  element 
manifest,  it  is  however  subordinate  to  the  motive  of  the  performance  or 
play.  The  stage  material,  furniture,  is  forgotten,  lost  in  the  functions  of  the 
play.  Man's  body  is  the  stage  accoutrements  and  persons.  The  drama, 
the  play,  is  the  physiology,  the  function.  Interpreted,  this  means  that  func- 
tion determines  structure,  not  structure  function.  Progressive  motion  in 
animals  has  traumatized,  frictiomzed,  the  proximal  end  (brain),  enticing 
increasing  blood  supply  (friction)  and  consequent  increase  of  substance 
arises,  i.  e.s  bumping  one's  head  against  the  universe  develops  the  brain. 
Lincoln's  body,  that  is,  his  anatomy,  his  stage  accoutrements  are  dead,  how- 
ever, Lincoln,  master  of  men,  his  play,  his  physiology,  his  function  progresses 
unabated.  John  Brown's  body,  his  physical  stage  accoutrements,  is  dead 
but  his  function  of  liberty  moves  on  forever,  even  to  the  latest  Russian  cry 
for  freedom.  The  staging,  the  physical  accoutrements,  of  Uncle  Tom's 
Cabin  have  long  disappeared.  However,  the  motive  of  the  play,  the  func- 
tion of  the  drama,  which  was  the  freeing  of  the  black  men,  has  also  ceased  as 
the  object  of  the  play  had  been  accomplished.  The  parallel  between  the 
field  of  music  and  bilology  or  physiology  is  striking.  Pipes  and  strings  are 
the  anatomy  of  music,  but  music  itself,  the  ultimate  object,  is  not  pipes  and 
strings.  It  consists  of  a  pleasing  succession  of  agreeable  sounds — music  is 
the  physiology  of  the  pipes  and  strings.  The  pipes  and  strings — the  anatomy 
— are  made  to  functionate  as  a  unit  through  physiology,  which  rules  anatomy. 
The  several  instruments  must  work  in  harmony — as  a  unit — to  produce  the 
object,  which  is  the  orchestra.  Sound  is  itself  an  element,  unrelated,  unclassi- 
fied, having  neither  predicate  nor  attribute  and  cannot  therefore  be  confused 
with  music — which  is  the  pleasing  succession  of  agreeable  sounds  to  the 
human  sense  and  purposely  designated  for  that  object.  The  only  functional 
value  of  sound  is  to  be  a  pleasant  succession. 

Physiology  harmonizes  different  structures  as  music  does  pipes  and  strings 
into  a  functionating  unit.     As  the  instruments  in  the  orchestra  must  subserve 


436 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


the  purpose  of  the  musician 
cells — organs — in  the  body 


HYRTL'S  EXSANGUINATED 
RENAL  ZONE  (H,  H,  H.) 
Fig.  111.  Corrosion  anatomy. 
Left  kidney.  H,  H,  H,  is  what  I 
term  Hyrtl's  exsanguinated  zone. 
A,  B,  equatorial  line  of  lateral 
longitudinal  renal  border.  D,  dor- 
sal vascular  renal  blade.  V,  ven- 
tral vascular  renal  blade.  H,  H, 
H,  indicates  the  course  of  Hyrtl's 
exsanguinated  renal  zone  or  the 
elective  line  of  renal  cortical  in- 
cision with  minimum  hemorrhage 
— located  l/2  inch  dorsal  to  the 
lateral  longitudinal  renal  border. 
The  quantity  of  sympathetic 
nerves  required  for  the  kidney 
may  be  estimated  by  the  number 
of  arteries  in  its  two  vascular 
blades. 


— which  is  music — so  the  aggregative  molds  of 
must  subserve  the  dignified  purpose  of  physi- 
ology, i.  e.,  a  functionating  unit  which  dom- 
inates, determines  and  precedes  structure. 
We  concede  to  our  materialistic  friend  the 
physical  basis  of  life  and  that  function  is  not 
purely  phychic  in  character.  In  the  final 
analysis  of  structure  or  function  we  are  deal- 
ing with  the  arrangement  of  matter,  and  that 
is  structure.  To  illustrate  that  function,  phys- 
iology, dominates  structure,  anatomy,  one  need 
only  study  large,  noninfected,  pelvic  peri- 
toneal exudates.  Not  long  after  pelvic  peri- 
toneal exudate  arises  blood  vessels  begin  to 
appear  in  the  mass,  projecting  their  course 
through  it,  followed  by  lymph  vessels  and 
nerves  as  well  as  an  endothelial  covering, 
until  the  jelly-like  unorganized  mass  is  a  living 
structural  unit,  a  functionating  organism.  In 
this  case  did  not  physiology  dominate,  deter- 
mine, precede  anatomy? — yes,  physiology  is 
the  central  motive  power  of  life.  Darwin 
recognized  this  principle  throughout  his  inves- 
tigation of  the  origin  of  species.  Through 
physiology  he  claimed  he  could  modify  species 
by  environments  that  in  a  few  years  they 
could  be  scarcely  recognized.  By  environ- 
mental influences  he  could  modify  through 
physiologic  forces  the  traits  or  characteristics. 
Observe  how  the  patent  foramen  ovale,  mod- 
ifies circulation — i.  e.,  physiology — produces 
the  clubbed  fingers.  Dr.  Thomas  G.  Atkinson 
in  the  editorials  of  the  Medical  Standard  for 
July  and  Oct.,  1906,  writes  instructively  and 
strikingly  on  .pathologic  physiology.  He  claims 
that  the  influences  which  determine  structure 
operate  from  the  complex  to  the  simple,  e.  g., 
the  larger  functions  of  the  body  peristalsis, 
circulation,  cerebration — are  the  simplified 
specific  expressions  of  the  multiple,  complex, 
impressions  produced  on  the  body  in  general 
by  circumstances  and  environment  and  these 
consequently  are  the  determining  causes  of 
cellular  structure.  Physiology  is  the  father  of 
anatomy,  of  form,  of  characteristics,  of  hyper- 


GENERAL  PATHOLOGIC  PHYSIOLOGY  437 

trophy.  A  myoma  in  the  uterine  wall  or  an  ovum  on  the  endometrium 
are  the  causes  of  uterine  hypertrophy — increased  blood  supply  has  multiplied 
the  cellular  elements  of  the  uterus.  Physiology  or  direction  of  excessive 
blood  to  the  uterus  has  determined  the  multiplication  of  cellular  struct- 
ure And  thus  the  amphioxis  and  similar  animals  that  superseded  and 
repeated  his  structure  bumped  their  heads  against  the  world's  physical  forces, 
developing  the  four  skull  vertebra  and  multiplying  their  cerebral  cells  by 
enticing  blood,  due  to  the  cerebral  trauma.  The  Japanese  have  long  bodies 
and  short  legs  because  they  do  not  use  the  legs  sufficiently  to  secure  blood. 
Sitting  on  chairs  would  entice  more  blood  for  larger  legs.  The  lessons  to  be 
drawn  from  these  views  are  that  structure  has  no  power  to  modify  itself.  It 
is  perverted  function  that  alters  structure — pathologic  physiology  is  the 
father  of  it.  Again  Dr.  Atkinson  claims  that  perverted  function,  pathologic 
physiology,  operates  from  the  complex  to  the  simple.  Pathologic  physiology 
finally  terminates  by  registering  itself  as  altered  adjustment  of  cellular  struct- 
ure in  accordance  with  the  perverted  function  at  issue.  Structural  changes 
as  a  rule  are  the  final  responsive  reaction  of  cell  arrangement  to  pathologic 
physiology,  having  their  origin  in  the  complex  relations  between  organism 
and  environments  and  operating  through  the  less  and  less  complex  physiologic 
systems  of  the  body.  The  skillful  and  scientific  physician  can  discern  the 
origin  and  course  of  pathologic  physiology  and  apply  the  appropriate  advice, 
drug  or  scalpel,  first  to  correct  the  function  and  second  to  correct  the  struct- 
ure. 

The  Chief  Duty  of  a  Physician  is  to  Correct  Function. 

As  nine-tenths  of  illness  is  so-called  medical  and  one-tenth  so-called  surgi- 
cal, practically  the  sphere  of  a  physician's  influence  is  limited  to  the  field  of 
pathologic  physiology,  which  lies  between  normal  physiology  and  pathologic 
anatomy — the  zone  of  pathologic  physiology. 

The  common  functions  of  viscera  (sensation,  peristalsis,  absorption, 
secretion)  do  not  perform  uniformity  throughout  the  same  visceral  tract  and 
hence  demand  special  attention  in  physiology,  e.  g.,  secretion  is  more  promi- 
nent in  the  proximal  end  (cerebrum)  of  the  tractus  intestinalis  while  absorp- 
tion is  more  pronounced  in  the  distal  end  (sympathetic).  These  views  should 
be  borne  in  mind  when  observing  pathologic  physiology.  In  excessive  secre- 
tion there  is  not  only  an  expenditure  of  energy  but  also  a  loss  of  material  from 
the  body.  Physiology  deals  with  the  sources  of  energy  and  the  transforma- 
tion of  energy.  The  practically  wise  physician  seeks  to  trace  through  the 
deviating  functions  the  source  of  erroneous  energy. 

In  the  consideration  of  physiology  or  pathologic  physiology  the  nervous 
system  must  be  considered  a  presiding  genius.  E.  g.,  food  within  the  duode- 
num incites  both  the  liver  and  pancreas  to  secrete  through  a  nervous  mechan- 
ism for  it  appears  that  if  bile  and  pancreatic  juice  become  mixed  in  Vater's 
diverticulum  or  immediately  on  arrival  within  the  duodenum,  the  power  of 
the  succus  pancreaticus  is  doubled.  It  is  well  to  know  for  practical  therapeu- 
tics (pathologic  physiology)  that  adrenalin —  a  product  of  the  adrenal  medulla 


438  THE  ABDOMINAL  AND  PELVIC  BRAIN 

— circulating  in  the  blood  appears  necessary  for  the  excitation  of  any  nervus 
vasomotorius.  The  thyroid  gland  manufactures  some  substance — thyro-iodin 
— which  aids  in  the  proper  growth  of  body  tissues  and  also  for  the  normal  dis- 
charge of  the  cerebral  functions.  The  fetus  during  gestation  secretes  some 
substance  which  aids  in  enlarging  the  mammary  gland.  The  ovary  secretes 
a  substance  which  preserves  sex  and  nervous  characteristics.  Hence  with 
increasing  knowledge  of  physiology  we  may  be  able  to  isolate  these  sub- 
stances— adrenalin,  thyro-iodin,  ovarian  secretion,  secretions  of  pregnancy 
which  induce  mammary  hypertrophy,  etc.,  etc. — and  in  their  isolation  place  a 
list  of  therapeutic  messengers  at  our  command  which  will  correct  the  patho- 
logic physiology  of  bodily  organs.  With  broader  knowledge  of  physiology 
present,  therapeutic  nihilism  will  be  replaced  by  rational  therapeutics  which 
rest  on  physiology,  the  solid  ground  of  nature. 

The  results  from  the  study  of  the  four  grand  common  functions  of  viscera 
(sensation,  peristalsis,  absorption,  secretion)  must  be  the  rock  and  base  of 
our  authority  in  pathologic  physiology. 

Irritable  weakness  of  the  nervous  system  presents  inferior  anatomy  and 
physiology.  The  subject  of  pathologic  physiology  will  force  us  to  study 
the  stigmata  of  function.  It  is  noteworthy  that  before  the  days  of  legitimate 
specialism  few  practical  stigmata  were  recognized.  At  present  every  spe- 
cialty has  a  chapter  of  abnormalities,  of  stigmata.  In  fact,  the  study  of 
abnormalities  has  proceeded  to  such  a  degree  that  a  majority  of  individuals 
are  docketed  with  telltale  stigmata  of  some  sort  or  kind.  The  pathologic 
physiology  or  stigmata  of  individuals  may  with  impressive  instruction  be 
termed  "habitus,"  by  which  prefix  we  may  distinctly  designate  certain  classes 
of  subjects.  We  have  the  habitus  phthisicus,  habitus  nervosus,  and  the 
ensemble  of  certain  symptoms  may  well  be  termed  habitus  splanchnoptoicus. 
The  habitus  is  an  expression  of  inherited  weakness,  defect.  It  presents  the 
idea  that  inferior  anatomy  and  inferior  physiology  has  been  transmitted  to 
or  acquired  by  the  individual.  The  tendency  of  modern  study  is  to  accentuate 
the  functional  aspect  of  disease;  hence  it  is  this  method  of  study  that  has 
taught  that  there  is  an  abnormality  of  function.  The  mind  is  a  good  source 
of  pathologic  physiology,  as  by  concentrated  thinking  one  can  congest 
excessively  an  organ,  e.  g.,  genitals,  brain.  There  is  frequently  more  in  the 
physician's  suggestions  than  in  his  medicine. 

Rational  Medicine  alone  will  stand  the  test  of  science  and  time.  Rational 
medicine  must  be  the  medical  amazon  of  truth,  from  which  will  be 
eliminated  the  false  lateral  issues,  tangenital  fads,  distorted  views  of  the 
unbalanced  and  the  knave.  Rational  medicine  must  be  founded  on  the  solid 
ground  of  Nature  to  stand  forever.  Will  the  teachings  and  knowledge  of 
pathologic  physiology  aid  the  physician  to  exactuate  more  rational  practice? 
The  comprehension  of  pathologic  physiology  will  extend  the  physician's 
views  of  physiology,  which  should  resume  its  original  basic  position  in  medicine. 
The  future  of  clinical  medicine  lies  in  the  direction  of  pathologic  physiology. 
Rational  medicine  consists  in  the  application  of  scientific  laboratory  methods 
to  the  ambulatory  and  bedside  patient.     However,   the  laboratory  seems  to 


GENERAL  PATHOLOGIC  PHYSIOLOGY  439 

advance  periodically,  beyond  clinical  application.  In  the  field  of  science  and 
investigation  there  is  continually  clashing  of  opinions,  with  statements  and 
counter  statements,  with  evidence  and  counter  evidence,  from  which  estab- 
lished rules  of  practice  evolve.  The  principles  of  science  require  during  the 
progress  of  discoveries,  revision,  reconsideration,  and  recasting. 

The  perfection  of  physiological,  chemical,  and  pathologic  knowledge, 
with  consequently  improved  technique,  will  enable  the  clinician  to  advance 
on  the  citadel  of  disease  rationally  during  the  premature  stage  of  pathologic 
physiology  with  more  practical  hope  of  success.  Cardiac  irregularity,  palpa- 
tation  (which  chiefly  rests  on  vigorous  muscle  or  myocardium)  is  generally 
pathological  physiology,  or  abnormal  disordered  function  (excessive,  deficient 
or  irregular  peristalsis)  and  often  a  nervous  manifestation  only.  The  function 
or  the  physiology  of  the  cardiac  ganglia  (Remak's,  Bidder's,  Ludwig's,  and 
Schmidt's)  have  become  temporarily  disordered,  pathological,  wild,  irregular, 
yet  no  pathological  anatomy  can  be  detected.  It  is  well  enough  to  attempt 
to  be  scientific  in  explanation  to  the  student,  that  cause  and  effect  are  logical 
sequence,  yet,  also,  to  admit  that  we  cannot  detect  the  cause  of  cardiac  palpi- 
tation in  any  existing  pathological  anatomy — it  is  pathological  physiology, 
disordered  functions,  through  nonrecognized  channels.  Pathological  physiol- 
ogy alone  will  explain  the  irritable  bladder;  the  cystoscope  does  not  reveal 
the  pathological  anatomy.  The  vesical  apparatus  is  acting  unusually,  it  is 
assuming  an  abnormal  course.  I  have  noted  such  bladders  for  years;  they 
afflict  the  possessor  by  frequent  evacuations,  by  loss  of  sleep,  and  broken 
rest.  Who  will  attempt  to  explain  the  surface  anesthesias  by  pathological 
anatomy?  They  are  here  to-day  and  there  to-morrow.  Many  a  time  and  oft 
have  I  noted  the  pharyngeal  anesthesia  in  hysteria ;  in  fact  one  can  apply  a 
uterine  sound  vigorously  to  the  surface  of  the  pharynx  without  inducing 
nausea  or  reflex  muscular  action. 

We  have  no  more  appropriate  terms  to  apply  to  these  phenomena  than 
pathological  physiology,  disordered  function.  In  practice  of  medicine  the 
student  should  be  instructed  in  physiological  principles  and  not  that  he  is 
always  to  attempt  to  remove  changed  structures  by  his  remedies  or  scalpel. 
The  practice  of  medicine  is  the  practice  of  common  sense.  We  are  to  use 
means  to  an  end.  For  example,  if  a  frog's  heart  recently  removed  is  placed 
in  a  warm  physiological  salt  solution,  it  will  perform  its  peristalsis  for  a  time 
and  cease;  now,  I  can  renew  its  peristalsis  by  stimulation;  the  stimulant 
may  be  an  icicle,  electric  current,  a  hot  steel  needle,  or  a  current  of  water  or 
air.  The  chief  duty  of  the  profession  is  to  aid  in  the  resumption  of  normal 
functions,  not  merely  attempt  to  discover  some  pathological  anatomy  or 
changed  structure,  for  it  would  waste  valuable  time.  We  should  cultivate 
pathological  physiology  rather  than  surgery,  as  it  will  be  the  vast  future 
therapeutical  field  for  nine-tenths  of  illness,  whereas  surgery  is  of  value  in 
about  one-tenth  of  illness. 

The  mind  is  frequently  the  organ  that  needs  the  stimulant  of  which 
quacks,  patent  medicines,  knaves  and  pretenders  take  advantage.  Patholog- 
ical physiology  recognizes  the  influence  of  mind  over  matter.     The  sensible 


440 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


physician  realizes  that  suggestions  are  a  powerful  aid  to  peristalsis,  absorp- 
tion, secretion  and  sensation,  to  the  restoration  of  visceral  function,  and 
though  the  honorable  physician  may  not  make  the  bold,  false  assertions  of 
the  quack,  he  can  suggest  honest,  legitimate  aid  and  comfort  to  the  patient. 
The  honest  physician  is  se- 
cret and  reticent.  The 
quack  is  blatantly  false. 
Secrecy  and  reticence  is  bet- 
ter than  falsehood.  The 
physician  can  and  should  be 
an  honest  man.  The  physi- 
cian comprehending  patho- 
logic physiology  becomes 
master  of  suggestions  for  the 
patient's  benefit.  The  med- 
ical profession  cannot  afford 
to  leave  the  influence  of 
mind  over  matter,  the  field 
of  suggestive  therapeutics, 
to  the  quack  and  knave. 
The  world  of  knowledge  is 
our  parish.  To  alleviate 
suffering  and  prolong  life 
from  rational  demonstra- 
tions of  science  is  our  duty. 
To  treat  the  sick  by  any 
legitimate  means  is  our  priv- 
ilege. 

Diagnosis. — T  h  e  diag- 
nosis of  functional  deviation 
or  abnormal  visceral  action 
is  the  rock  and  base  in  path- 
ological physiology.  This 
view  indicates  that  the  phy- 
sician understands  the  physiology.  First  and  foremost  is  the  diagnosis, 
i.  e.,  what  abnormal  course  are  the  functions  assuming?  Disease  is  abnor- 
mal physiology,  and  the  sooner  physiological  deviation  is  diagnosticated, 
the  sooner  may  effective  remedial  agents  be  instituted.  To  be  useful 
to  a  patient,  the  incipient  stage  of  diseases,  i.  e.,  premature  pathologic  physi- 
ology, must  be  detected  in  order  to  check  the  progress  of  the  abnormal  func- 
tion before  pathologic  anatomy  establishes  itself.  We  must  accomplish  the 
diagnosis  by  all  known  aid,  medical  technique,  and  laboratory  methods. 

Pathologic  physiology  will  rest  on  laboratory  methods  for  rational 
knowledge  and  practical  application.  Laboratory  methods  are  valuable 
assets  to  a  physician  because  they  will  increase  his  business  of  rational  appli- 
cation  and   success.     The   physician's   self-confidence,    which    arises    from 


CORROSION  ANATOMY 

Fig.  112.  Left  kidney,  dorsal  surface  (D)  dorsal 
vascular  blade. — H,  H,  H,  indicates  Hyrtl's  exsanguin- 
ated renal  zone,  or  the  elective  line  of  incision,  one-half 
inch  dorsal  to  the  lateral  longitudinal  renal  border. 
Observe  that  the  elective  line  passes  to  or  invades  the 
ventral  renal  vascular  blade  at  the  proximal  and  distal 
poles.  Hyrtl's  zone  is  irregular  at  the  renal  poles. 
The  dorsal  vascular  renal  blade  is  the  smaller.  Observe 
the  quantity  of  nervus  vasomotorius  required  to  en- 
sheath  the  renal  arteries  with  close  fenestrated,  network 
of  plexuses. 


GENERAL  PATHOLOGIC  PHYSIOLOGY 


441 


accurate  knowledge,  begets  confidence  in  the  patient,  and  this  increases  his 
power  and  clientele.  Laboratory  methods  increase  the  physician's  efficiency, 
and  this  contributes  to  his  professional  attainments.  Laboratory  methods 
are  invaluable  to  the  physician  himselt  for  his  own  rational  view  of  any  dis- 
ease. Practically,  patients 
are  willing  to  recompense  a 
physician  according  to  his 
ability  and  attainments. 
The  day  is  not  distant  when 
the  physician's  power  to 
diagnosticate  disease  will  be 
measured  by  his  laboratory 
methods,  especially  in  the 
incipiency  or  in  the  stage 
of  pathologic  physiology. 
The  judgment  of  the  physi- 
cian will  be  heavily  taxed  as 
to  prognosis.  Unfortunately 
some  cases  of  splanchnopto- 
sia  appear  with  neurasthe- 
nia, as  an  integral  part,  or 
splanchnoptosia  is  imposed 
on  the  subject  of  hysteria. 
Neurasthenia  and  hysteria, 
though  not  primary  in 
splanchnoptotics,  easily 
thrives  among  them.  It  is 
an  indication  of  defective 
knowledge  and  judgment  to 
attribute  symptoms  of  ne- 
phroptosia  or  gastroptosia 
that  belong  to  general 
splanchnoptosia. 

Blood  Volume. — Patho- 
logical physiology  combines 
rational  views  of  living  or- 
gans, more  than  that  merely 
based  on  pathological  an- 
atomy. For  example,  when 
pathological  physiology  of 
the  kidney  is  studied,  the 
instructor  must  take  rational 
and  comprehensive  views  of  the  renal  viscus.  Pathological  physiology 
of  the  kidney  takes  into  account  the  condition  of  the  kidney,  the  constituents 
of  the  blood  and  volume  of  blood  that  streams  through  the  organ.  The 
discussion   of  these   three   subjects   in   regard  to   the  kidney  lends   a   com- 


HYRTL'S  EXSANGUINATED  RENAL  ZONE 

Fig.  113.  Corrosion  anatomy,  left  kidney,  ventral 
view  (V)  ventral  renal  vascular  blade. — From  man  about 
forty-five  years  of  age.  The  ureter  was  injected  with 
yellow  wax.  The  ramus  dorsalis  renalis  was  injected 
with  celloidin  colored  with  red  sulphide  of  mercury. 
The  trunk  of  the  arteria  renalis,  including  the  ramus 
ventralis  renalis  was  injected  with  uncolored  celloidin. 
The  tissues  were  corroded  in  HNO3  for  two  weeks. 
A.  R.,  Arteria  renalis  sinistra.  2,  ureteral  pelvis.  3, 
proximal  ureteral  isthmus.  H,  H,  H,  indicates  Hyrtl's 
exsanguinated  renal  zone.  It  may  be  noted  on  the 
ventral  renal  surface  that  the  renal  dorsal  vascular  blade 
overlaps  or  invades  the  ventral  vascular  blade  at  the 
proximal  and  distal  renal  poles.  Hyrtl's  exsanguinated 
renal  zone  is  not  equatorial  at  the  proximal  or  distal 
renal  poles  nor  in  the  central  portion  of  the  kidney. 
The  elective  line  of  renal  incision  to  invade  the  ureteral 
pelvis  with  minimum  hemorrhage  is  located  l/2  inch 
dorsal  to  the  lateral  longitudinal  renal  border  in  the 
central  segment  of  the  kidney  and  is  about  two  inches 
in  length.  The  quantity  of  nervus  vasomotorius  may 
be  estimated  by  the  number  of  arteries  and  ducts  pres- 
ent. 


442  THE  ABDOMINAL  AND  PELVIC  BRAIN 

prehensive  view  to  the  student  in  making  a  diagnosis  on  the  living  subject, 
e.  g.,  the  functional  capacity  of  a  kidney  is  the  rational  test,  not  albumen 
and  casts.  It  is  common  to  observe  much  variation  in  the  quantity  of 
urine,  inexplainable,  except  by  pathological  physiology,  for  urinalysis  offers 
none.  Pathological  physiology  teaches  that  the  circulation  of  an  organ  is  a 
fundamental  factor  in  comprehending  diseased  conditions.  The  teacher  who 
does  not  comprehend  varying  phases  of  circulation  of  the  female  genitals  in 
the  different  stages  of  pueritas  (quiescent),  pubertas  (development),  menstrual 
(functionating),  gestation  (functionating),  puerperal  (involution),  climacterium 
(subsidence),  and  senescence  (quiescent),  makes  a  defective  gynecological 
teacher.  No  organs  except  the  kidney,  offer  such  an  extensively  varied  base 
to  illustrate  pathological  physiology  of  the  tractus  vascularis  as  the  female 
genitals. 

The  circulation  of  an  organ  quotes  its  value  in  the  animal  economy;  it 
rates  its  function.  Each  organ  is  supplied  by  arteries  which  have  automatic 
visceral  ganglia,  which  regulate,  govern,  the  volume  of  blood  which  flows 
through  them.  The  automatic  visceral  ganglia  tell  the  story  why  the  volume 
of  blood  changes  so  much  in  different  conditions  of  the  organs  when  the 
parenchymatous  cells  of  an  organ  functionate,  as  the  liver  during  digestion, 
the  uterus  during  gestation,  the  cerebrum  during  thinking  (cerebration),  the 
blood  volume  is  increasingly  directed  to  the  organ  through  the  automatic  vis- 
ceral ganglia,  dilating  the  arteries.  Hyperaemia  indicates  the  functionating 
brain,  kidney,  and  genitals,  and  these  organs  occupy  vast  considerations  in 
practice.  Pathological  physiology  indicates  that  great  benefit  is  secured  by 
controlling  circulation,  blood  volume,  by  checking  peristalsis  through  with- 
holding food;  controlling  diet  controls  the  blood  constituents  to  a  certain 
degree.  Bier's  method  of  artificial  congestion  is  employing  pathological 
physiology  (in  the  tractus  vascularis)  for  the  purpose  of  curing  chronic 
inflammation. 

Treatment  of  Pathological  Physiology. — The  treatment  of  pathological 
physiology  consists:  1.  In  the  detection  and  removal  of  causes;  2,  the 
rational  regulation  of  visceral  function,  a,  by  fluids;  b,  by  foods;  3,  habitat; 
4,  avocation;  5,  prophylaxis. 

1.  The  Detection  and  Removal  of  Their  Causes. — The  detection  of  the 
cause  in  pathological  physiology  requires  the  best  head  and  the  finest  analy- 
sis. The  detection  of  a  rectal  ulcer  or  fissure  as  the  cause  of  innumerable 
reflexes  is  a  credit  to  the  diagnostician.  The  recognition  of  damaging  effects 
of  preputial  adhesions  is  important.  The  glans  penis  or  clitoris  is  like  an 
electric  bell  button,  the  pressing  or  irritation  of  which  rings  the  whole  organism 
into  pathological  physiology.  A  cinder  in  the  eye  is  a  grand  master  of  patho- 
logical physiology.  I  have  known  the  detection  and  removal  of  a  bleeding, 
proximally  located,  rectal  polypus  to  save  a  child's  life  and  make  a  physician's 
reputation.  This  little  rectal  polypus  had  bled  and  escaped  being  examined 
for  a  whole  year  by  numerous  consultants.  I  know  a  gynecologist  who  did 
five  operations  on  a  woman's  genitals  for  pain  in  the  distal  abdomen.  She 
became  no  better,  but  worse.     The  cause  of  all  her  pain  was  discovered  by  a 


GENERAL  PATHOLOGIC  PHYSIOLOGY  443 

consultant,  who  found  a  marked  spinal  gibbus  or  kyphosis  of  tuberculous 
nature  at  the  junction  of  the  dorsal  and  lumbar  vertebrae.  The  reflected  pain 
from  kyphosis  had  dislocated  the  gynecologist's  mind,  to  make  a  scapegoat 
of  the  genitals.  Frequently  infected  groin  glands  are  associated  with  an 
infected  corn  on  a  toe.  A  decayed  tooth  may  cause  earache.  I  knew  a 
woman  of  twenty-four  years,  experienced  some  eight  months  of  crucial 
suffering  from  pathological  physiology.  She  was  examined  by  one  physician 
who  said  her  ovaries  should  be  removed,  two  others  said  that  she  must  have 
her  appendix  extirpated,  one  physician  diagnosticated  neurosis,  another  indi- 
gestion, finally  a  physician  was  employed  who  found  she  had  a  ureteral  calcu- 
lus and  removed  it  after  which  she  gained  thirty  pounds  in  eight  weeks. 
This  an  excellent  example  to  demonstrate  that,  though  pathological  physiol- 
ogy allows  ample  time  for  diagnosis  and  prophylaxis,  yet  it  requires  the  finest 
head  with  the  finest  skill  of  analysis  to  interpret  the  signification  of  abnormal 
visceral  function.  Hepatic  calculus  may  introduce  pathological  physiology 
into  the  tractus  intestinalis  and  associated  visceral  tracts,  but  it  requires 
experience,  accumen,  and  skill  to  detect  the  cause  of  pathological  physiology. 

2.  Rational  Regulation  of  Visceral  Function  by  Visceral  Drainage. — 
Pathological  physiology  teaches  the  supreme  importance  of  visceral  drainage, 
of  maintaining  in  normal  attenuated  solution  bodily  secretions.  It  teaches 
the  benefit  of  removing  the  debris  of  waste  laden  blood  by  means  of  fluids. 
When  the  patient's  blood  and  organs  are  saturated  with  waste  laden  material, 
he  is  unprepared  to  resist  the  attacks  of  disease ;  he  is  prepared  for  irritation, 
for  reflexes  or  neurotic  explosions.  With  scientific  views  of  pathological 
physiology,  the  correction  of  functional  deviation  with  rational  ideas  of  vis- 
ceral drainage,  the  physician  holds  the  key  of  prophylaxis  against  the  formation 
of  pancreatic,  hepatic,  and  renal  calculus.  With  ample  visceral  drainage, 
with  sufficient  fluids  taken  at  regular  intervals  for  visceral  functions,  the  pan- 
creatic, biliary,  and  renal  secretions  would  seldom  precipitate  their  salts,  and 
colloid  material  or  cohesive  ground  substance  of  calculus  would  be  so  atten- 
uated that  calculus  would  not  form. 

Viscera  should  functionate  at  a  normal  maximum  for  bodily  safety  and 
protection.  Pathological  physiology  takes  into  account  of  the  composition  of 
glandular  secretion,  as  the  pancreatic,  hepatic,  and  renal,  with  the  view  that 
pancreatic,  hepatic,  and  urinary  salts,  especially  urates,  should  be  maintained 
in  attenuated  solution  by  ample  fluids,  that  no  calculi  may  form.  A  study 
of  the  remedies  recommended  as  uric  acid  solvents  or  eliminators  of  uric  acid 
reveals  the  data  that  are  composed  of  two  ingredients,  viz. :  (a)  alkali,  (b) 
water.  The  plan  is  to  alkalinize  the  blood  current,  and  thus  render  the  uric 
acid  more  soluble  and  promote  its  elimination.  The  administration  of  an 
alkali  to  dissolve  uric  acid  concretions  is  of  limited  value.  Alkalies  and  uric 
acid  are  solvent  in  vitro,  but  cannot  accomplish  the  same  in  vivo.  The 
alkalies  are  ingested  with  the  foods,  making  soluble  urates.  After  all,  the 
ingestion  of  alkalies  in  food  and  fluid  cannot  alter  materially  the  uric  acid. 
However,  the  chief  virtue  lies  in  the  quantity  of  water  ingested  at  regular 
intervals  during  the  day.     The  water  is  the  chief  efficacious  ingredient  in  uric 


444 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


acid  remedies.  The  water  increases  the  blood  volume  which  in  turn  produces 
a  powerful  stream  irrigating  the  tractus  urinarius  and  maintaining  the  uric 
acid  in  attenuated  mechanical  suspension. 


*u  FuP'  "L14'     This  illustration  represents  the  lymph  glands  or  nodes  located  in  the  course  of 
the  blood  vessels.     The  lymph  nodes  are  highly  supplied  by  the  nervus  vasomotorius. ' 

Pathological  physiology  indicates  that  the  composition  of  the  blood  is 
essential  to  health,  and  that  its  salts  should  not  be  concentrated  or  abnormal 
in  relation.     Pathological  physiology  accounts  for  the  various  reflexes  and 


GENERAL  PATHOLOGIC  PHYSIOLOGY  445 

disordered  functions  from  the  irritation  of  waste  laden  blood  and  the  damaged 
functions  resulting  from  nephrolithiasis  and  cholelithiasis.  Pathological 
physiology  dictates  that  the  ample  fluids  at  regular  intervals,  visceral 
drainage,  is  the  great  safeguard  against  waste  laden  blood;  it  is  the 
prophylaxis  against  cholelithiasis,  pancreatolithiasis,  and  nephrolithiasis.  By 
the  time  that  pathological  anatomy  is  demonstrable,  damaging  structural  mis- 
chief is  established,  and  not  infrequently  with  a  lifelong  cicatrix.  The  vast 
majority  of  palpitations  of  the  heart  cannot  be  explained  on  pathological 
anatomy,  which  has  been  the  tendency  of  medical  progress  for  the  past 
decade.  The  nervous  system  so  intimately  and  profoundly  connects  the  vis- 
ceral system,  so  solidly  and  compactly  anastomosis  the  viscera,  that  approp- 
riate stimulation  administered  to  one  visceral  tract  tends  to  induce  adjacent 
visceral  tracts  to  normal  functions  and  consequent  ample  visceral  drainage, 
e.  g.,  ample  volume  of  fluid  in  the  tractus  vascularis  enhances  the  volume  and 
flow  of  the  tractus  lymphaticus,  and  the  general  glandular  system  increases 
its  flow,  notably  the  perspiration,  from  the  tractus  cutis.  Stimulation  of  the 
cutaneous  surface  by  massage  or  salt  rubs  not  only  stimulates  the  cutaneous 
nerve  periphery,  but  also  the  circulation  and  tractus  perspiratorius.  Stimu- 
lation of  the  tractus  muscularis  by  exercise  stimulates  and  enhances  the  func- 
tion of  all  visceral  tracts. 

A.  Visceral  Drainage  by  Fluids. — About  eighty  per  cent  of  the  body  is 
fluids  while  about  twenty  per  cent  is  solids.  All  viscera  functionate  by 
means  of  a  fluid  medium.  Fluid  forms  the  chief  distributing  or  circulatory 
agency  of  the  organism.  Liquid  is  essential  for  assimilation  and  metabolism. 
Water  forms  the  bulk  of  the  softer  tissue  and  is  an  important  factor  in  the 
composition  of  the  harder.  Fluid  permeates  or  flows  through  all  the  bodily 
structures  by  osmosis  or  distinct  vessels.  Water  is  a  more  important  agency 
in  relating  the  individual  to  environments  than  food  or  air.  It  flows  univer- 
sally through  the  organism.  It  enters  mainly  through  the  tractus  intestinalis, 
and  escapes  through  the  mucous  membranes,  skin  and  the  chief  excretory 
ducts.  Water,  as  related  to  the  skin  and  lungs  in  the  form  of  liquid  vapor, 
affords  the  most  important  factor  in  controlling  the  temperature  necessary 
for  organic  existence.  Diet  consists  on  the  average  of  six  parts  liquid  to  one 
part  dry  material.  These  data  explain  why  Dr.  Tanner  and  others  could  fast 
such  a  length  of  time  on  drinking  water  only.  I  was  a  watcher  of  Dr.  Tan- 
ner's fasting  twenty-five  years  ago,  and  wondered  at  the  ease  and  apparent 
comfort  of  his  abstaining  from  food  so  many  weeks.  Water  is  more  essential 
for  the  growth  and  sustenance  of  the  vital  system  than  food.  The  most  effective 
diuretic  is  water.  One  of  the  best  laxatives  is  water.  One  of  the  best  and 
most  natural  stimulants  to  renal  epithelium  is  sodium  chloride  (one  half  to 
one  fourth  normal  salt  solution).  The  blood  contains  three-fifths  of  one  per 
cent  of  sodium  chloride.  Water  is  to  the  organism  what  oil  is  to  machinery — 
it  prevents  friction.  For  the  purpose  of  stimulating  normal  visceral  action 
(the  great  common  visceral  functions  are  peristalsis,  absorption,  sensation, 
secretion),  I  administer  eight  ounces  of  one-half  to  one-fourth  normal  salt 
solution  six  times  daily,  two  hours  apart.     (Note — Sodium  chloride  is  contra- 


446  THE  ABDOMINAL  AND  PELVIC  BRAIN 

indicated  in  parenchymatous  nephritis.)  Three  pints  (of  one-half  to  one- 
fourth  normal  salt  solution  efficiently  influences  the  renal  secretion  for  ample 
visceral  drainage.  Renal  drainage  should  be  sufficient  to  maintain  in  mechan- 
ical suspension  the  free  insoluble  uric  acid  to  prevent  calculus  formations. 
Also  it  should  be  sufficient  to  form  soluble  urate  combinations  with  sodium, 
potassium,  and  ammonium  salts. 

B.  Visceral  Drainage  by  Foods. — To  drain  the  viscera  by  appropriate 
foods  and  fluids  may  sound  paradoxical ;  however,  the  common  functions  of 
viscera — peristalsis,  absorption,  sensation,  secretion — are  initiated  and  main- 
tained by  fluid  and  food.  Rhythm  is  one  of  the  grand  physical  manifesta- 
tions. The  tubes  of  the  body  under  spiral  motion  assume  a  spiral  direction. 
Food  stimulates  the  tractus  intestinalis  through  its  sensitive  mucosa  to  con- 
tinual, rhythmical,  spiral  motion,  and  consequent  absorption  and  secretion. 
The  sodium  chloride  is  an  especial  stimulant  to  the  epithelium  of  the  tractus 
intestinalis.  To  drain  the  tractus  intestinalis,  foods  which  result  in  an  ample 
indigestible  fecal  residue  are  requisite  to  maintain  the  fundamental  peristalsis 
or  rhythm  necessary  for  its  life  of  absorption  and  secretion.  If  the  tractus 
intestinalis  be  stimulated  to  a  maximum  by  sufficient  appropriate  food  and 
fluid,  adjacent  visceral  tracts  from  their  intimate  nervous  connection  (through 
the  abdominal  brain),  will  share  and  assume  normal  function  (peristalsis, 
absorption,  secretion,  sensation).  Rational  foods  must  contain  appropriate 
salts  whose  basis  may  form  combinations  which  are  soluble,  as  sodium,  potas- 
sium, and  ammonium,  combined  with  uric  acid  and  urates  to  form  soluble 
urates. 

The  proper  foods  are:  Cereals  (oatmeal,  wheat,  rice,  graham  bread); 
vegetables  (practically  all  vegetables,  cooked) ;  albuminoids  (milk,  eggs,  but- 
termilk) ;  meats  (limited,  as  they  produce  excessive  uric  acid  formations.  A 
mixed  diet  is  therefore  most  rational. 

In  order  to  stimulate  the  epithelium  (sensation)  of  the  tractus  intestinalis, 
urinarius,  and  genitalis  and  the  endothelium  (sensation)  of  the  tractus  vascu- 
laris and  lymphaticus  with  consequent  increase  of  peristalsis,  sensation, 
absorption,  secretion,  in  the  five  visceral  tracts  I  employ  a  part  or  multiple 
of  an  alkaline  tablet  of  the  following  composition:  1,  Cascara  sagrada,  one- 
fortieth  grain ;  aloes,  one-third  grain ;  sodium  bicarbonate,  1  grain ;  potassium 
bicarbonate,  one-third  grain ;  and  magnesium  sulphate,  2  grains.  This  com- 
bination is  used  as  follows:  One-sixth  to  one  tablet  (or  more  as  required  to 
move  the  bowels  freely  once  daily)  is  placed  on  the  tongue  and  followed  by 
eight  ounces  of  water  (better  hot).  Also  at  10  a.  m.,  3  p.  m.,  and  at  bedtime 
one-sixth  to  one  tablet  is  placed  on  the  tongue  and  followed  by  a  glassful  of 
any  fluid.  In  the  combined  treatment  one  third  of  the  sodium  chloride  tablet 
(containing  eleven  grains)  and  (one-sixth  to  three)  alkaline  tablets  are  placed 
on  the  tongue  together  before  each  meal  and  at  10  a  m.,  3pm.,  and  bedtime, 
followed  by  a  glass  of  fluid.  The  six  glasses  of  fluid  may  be  water,  coffee, 
tea,  milk,  buttermilk,  cream,  eggnog — in  short,  a  nourishment.  This  method 
of  treatment  furnishes  alkaline  bases  (sodium,  potassium,  and  ammonium)  to 
combine  with   the   free  uric  acid  in  the  urine,  producing  perfectly  soluble 


GENERAL  PATHOLOGIC  PHYSIOLOGY  447 

alkaline  urates,  and  materially  diminishing  the  insoluble  free  uric  acid  in  the 
urine.  Also  the  alkaline  laxative  and  sodium  chloride  tablet  increase  the 
peristalsis,  absorption,  secretion,  sensation  of  the  tractus  intestinalis,  urina- 
rius,  vascularis,  lymphaticus,  genitalis,  which  aids  secretions  and  evacuation. 
I  have  termed  the  sodium  chloride  and  alkaline  laxative  tablets  the  vis- 
ceral drainage  treatment.  The  alkaline  and  sodium  chloride  tablet  inducing 
maximum  visceral  function  take  the  place  of  the  so-called  mineral  waters. 
I  continue  this  dietetic  treatment  of  fluids  and  foods  for  weeks,  months,  and 
the  results  are  remarkably  successful,  especially  in  pathologic  physiology  of 
visceral  tracts.  The  urine  becomes  clarified  like  spring  water  and  increased 
in  quantity.  The  tractus  intestinalis  becomes  freely  evacuated,  regularly, 
daily.  The  tractus  vascularis  maintains  an  active  peristalsis  and  full  volume. 
The  blood  is  relieved  of  waste  laden  and  irritating  material.  The  tractus 
cutis  eliminates  freely,  and  the  skin  becomes  normal.  The  appetite  increases. 
The  sleep  improves.  The  patient  becomes  hopeful;  natural  energy  returns. 
The  sewers  of  the  body  are  well  drained  and  flushed  to  a  maximum. 

3.  Habitat. — Habitat  has  chiefly  relations  to  the  environments  of  air, 
exercise,  heat,  cold,  moisture.  In  habitat  one  of  the  principle  factors  is  air. 
The  functions  of  the  lungs  are  sensation,  peristalsis,  absorption  and  secretion. 
It  is  through  the  great  function  of  respiration  that  the  internal  tissue  becomes 
related  to  the  external  world.  The  medium  of  exchange  between  the  internal 
tissue  and  the  external  world  is  the  blood.  The  blood,  an  universal  tissue,  a 
common  transporter  of  oxygen  and  carbonic  acid  gas,  plays  a  vast  role  in  the 
economy  of  organism.  The  red  blood  corpuscles  during  their  passage  through 
the  lung  (external  respiration),  automatically  appropriate  the  oxygen,  and 
after  their  return  (from  internal  respiration)  through  the  tractus  vascularis 
unburden  acquired  carbon  dioxide  into  the  expiring  air.  The  pathological 
physiology  of  respiration  is  a  wide  zone  and  especially  in  an  incipient  zone 
to  that  of  pathological  anatomy.  Its  pathological  physiology  is  frequently 
amenable  to  treatment.  The  respiratory  apparatus  has  methods  of  its  own 
to  correct  its  pathological  physiology,  as  cilia,  coughing  and  sneezing  to 
evacuate  harmful  material,  as  mucus  and  foreign  bodies.  The  grand 
remedial  agent  for  pathological  physiology  of  the  living  is  continuous, 
ample,   fresh  cold  air. 

4.  Avocation. — The  avocation  should  suit  the  individual  conditions.  In 
numerous  cases  the  labor  is  unsuitable  for  the  subject.  The  hours  are  too 
long,  the  work  is  excessive  or  severe  for  the  strength.  The  condition 
enhances  pathological  physiology,  rather  than  cures. 

5.  Prophylaxis.  —Prophylaxis  of  disease  is  the  tendency  of  modern 
medicine.  Pathological  physiology  teaches  the  control  of  disease  by  means 
of  diet,  fluid,  habitat,  avocation. 


CHAPTER   XXXIII. 
PATHOLOGIC   PHYSIOLOGY    OF   THE  TRACTUS  INTESTINALIS. 

O,  then  beware;  tlwse  wounds  heal  ill  that  men  do  give  themselves.— Shake- 
speare. 

The  tractus  intestinalis  possesses  three  original  segments — gastrium,  enteron, 
colon — which  differ  in  form  and  dimension,  anatomy  and  physiology;  how- 
ever, every  segment  possesses  the  four  common  visceral  functions — sensa- 
tion, peristalsis,  absorption,  secretion. 

The  physiology  of  the  tractus  intestinalis  is  peristalsis,  absorption,  secre- 
tion and  sensation;  its  object  is  to  afford  general  corporeal  nourishment. 
One  or  all  of  the  functions,  the  physiology  of  the  tractus  intestinalis  may 
present  pathologic  physiology  without  demonstrable  pathologic  anatomy. 

A  typical  example  of  pathologic  physiology  in  the  tractus  intestinalis  is 
emesis,  e.  g.,  by  some,  from  the  observation  of  a  fly  in  the  soup.  This  is 
disordered  function  introduced  so  rapidly  that  pathologic  anatomy  had  insuf- 
ficient time  to  become  established.  The  so-called  reflexes  are  pathologic 
physiology  not  pathologic  anatomy.  One  may  observe  pathologic  physiology 
where  a  herd  of  cattle  is  placed  on  a  boat  and  when  the  boat  starts  the  cattle 
become  excited,  nervous,  a  number  having  immediate  and  frequent  liquid 
stools.  The  peristalsis  and  secretion  of  the  tractus  instestinalis  liquifying 
the  feces  and  expelling  them — pathologic  physiology  but  not  pathologic  ana- 
tomy was  detectable.  A  typical  example  of  the  utility  of  pathologic  physiol- 
ogy in  the  tractus  intestinalis  is  the  diarrhea  of  puerperal  sepsis — which 
frequently  saves  the  patient.  Certain  kinds  of  food  produce  pathologic 
physiology.  It  is  an  excessive  fermentation — gas.  This  may  be  observed 
the  most  certainly  in  the  digestion  of  leguminous  substances,  e.  g.,  beans. 
Pathologic  physiology  may  be  manifest  by  excessive,  deficient  or  dispropor- 
tionate peristalsis,  absorption,  secretion  and  sensation.  The  practitioner 
observes  and  treats  the  following  conditions. 

(1).       PERISTALSIS  (EXCESSIVE,  DEFICIENT,  DISPROPORTIONATE). 

The  tractus  intestinalis  possesses  peculiar  physiologic  movements  known 
as  peristalsis,  vermicular  motion  passing  through  periodic  activity  and  repose. 
Though  each  segment  (gastrium,  enteron,  colon)  possesses  peristalsis  in  com- 
mon, however,  the  structure,  function  and  object  of  each  segment  is  so 
different  that  peristalsis  in  each  segment — gastrium,  enteron  and  colon — is 
best  studied  separately.  The  factors  which  initiate  motion  in  the  tractus 
intestinalis  are:  (a)  blood  supply;  (b)  ingesta;  (c)  secretion;  (e)  temper- 
ature; (f)  sensation. 

(a)  Excessive  peristalsis  (stomach).  Increased  gastric  movements  (path- 
ologic physiology)  may  arise  from  excessive  secretion  of  HC1,  hence  exces- 

448 


PHYSIOLOGY   OF  TRACTUS  INTESTIXALIS  449 

sively  rapid  gastric  evacuation.  Increased  gastric  movements  or  contractions 
may  arise  from  pyloric  obstruction.  Gastric,  enteronic  and  colonic  peristal- 
tic unrest  may  be  prominent  without  known  cause,  with  perhaps  an  irritable 
defective  nervous  system — a  kind  of  motor  neurosis.  The  splanchnic  nerves 
are  perhaps  the  chief  motor  nerves  of  the  digestive  tract.  The  peristaltic 
unrest  (pathologic  physiology)  is  eminently  manifest  in  certain  individuals  as 
evidenced  by  the  frequent  gurgling,  splashing  sounds  heard  when  standing  in 
close  proximity.  During  fright  excessive  intestinal  peristalsis  may  occur 
with  sudden  evacuation  of  the  colon.  Excessive  peristalsis  may  occur  during 
pregnancy  or  on  observation  of  disgusting  matters  (as  a  fly  in  the  soup), 
intense  decomposing  odors,  certain  forms  of  food  create  peristaltic  unrest. 
The  frequent  wild  and  disordered  peristalsis  in  the  digestive  tract  of  the  child 
is  based  on  pathologic  physiology — not  pathologic  anatomy.  It  rests  on  dis- 
ordered peristalsis  due  to  the  fact  that  Auerbach's  plexus  is  not  fully  devel- 
oped or  established  in  office.  The  cramps,  and  colic  and  emesis,  diarrhea, 
arise  and  disappear  so  quickly  that  insufficient  time  exists  for  pathologic  ana- 
tomy. Vomiting  is  pathologic  physiology  as  it  forcibly,  artificially  dilates 
the  cardiac  sphincter  of  the  stomach. 

(b)  Deficient  peristalsis.  The  most  typical  example  in  the  tractus  intes- 
tinalis  of  deficient  peristalsis  is  constipation — the  so-called  sluggish  bowels. 
Evacuation  of  the  digestive  tract  (especially  the  stomach  and  colon)  is  defec- 
tive, incomplete.  Dilatation  of  the  stomach  (generally  due  to  compression 
of  the  transverse  duodenum  by  the  superior  artery  vein  and  nerve)  results  in 
series  of  consequences  as  decomposion,  fermentation,  taxemia,  inability  to 
force  food  through  the  pylorus.  The  acute  gastric  dilatation  is  simply  an 
exacerbation  of  a  previous  dilatation.  I  have  shown  in  numerous  cadavers 
that  no  pyloric  obstruction  exists,  that  it  is  gastro-duodenal  dilatation  due  to 
compression  of  the  mesenteric  vessels.  Gastro-duodenal  dilatation  is  a  stage 
of  enteroptosia. 

(c)  Disproportionate  peristalsis  consists  of  non-uniform,  irregular,  dis- 
ordered muscular  movements.  It  is  peristalsis  uncontrolled  like  the  irregular 
invaginations  of  death  and  the  test  of  diagnosis  is  that  the  invagination  is  not 
pathologic  anatomy — simply  pathologic  physiology. 

(2).      SECRETION  (EXCESSIVE,   DEFICIENT,   DISPROPORTIONATE). 

(e)  Excessive  secretion,  pathologic  physiology  is  observed  in  diarrhea. 
Many  kinds  of  irritating  foods  induce  it.  Doubtless  excessive  secretion  is 
due  to  the  variations  in  HC1.  Chronic  supersecretion,  is  perhaps  connected 
with  superacidity.  Excessive  secretion  of  the  tractus  intestinalis  is  frequently 
found  in  neurotic  patients,  in  neurasthenics,  in  hysteria.  Hunger  plays  a 
role,  e.  g.,  when  a  hungry  subject  views  food.  Abdominal  secretion  occurs 
in  chronic  dyspepsia.  Hypersecretion  doubtless  depends  on  the  blood  volume 
in  the  stomach,  enteron  or  colon.  Hypersecretion  frequently  accompanies 
gastroptosia  (which  is  generally  gastro-duodenal  dilatation)  because  the  gas- 
troptosia  is  accompanied  by  stagnation  of  food  material  and  irritates  the 
gastric  wall.     The  fasting  stomach  may  present  supersecretion  on  reception 

29 


450  THE  ABDOMINAL  AND  PELVIC  BRAIN 

of  food  known  as  alimentary  supersecretion.  Hyper  chloridia  from  an 
unknown  cause.  Infectious  processes  induce  supersecretion  as  well  as  ulcer- 
ation and  epithelial  desquamation. 

In  the  duodenum,  the  most  important  segment  of  the  tractus  intestinalis, 
arrives  the  extra  glandular  secretion  succus  pancreaticus,  and  succus  bilis. 
These  naturally  abundant  extraglandular  secretions,  when  possessing  the 
pathologic  physiology  of  excess,  will  present  a  wide  varying  zone  of  effect  on 
nutrition.  The  excess  of  biliary  secretion,  pathologic  physiology,  is  difficult 
to  estimate  as  the  bile  is  re-absorbed  and  its  excessive  flooding  stream  prevents 
the  formation  of  biliary  concrements.  However,  we  know  that  in  driving 
cattle  several  miles  previous  to  slaughter  an  excess  of  bile  collects  in  the 
cholecyst— demonstrating  a  wide  range  of  variation  in  the  time  and  quantity 
of  biliary  secretion.  Excessive  biliary  secretion  may  be  the  cause  of  glycosu- 
ria allowing  insufficient  time  for  completion  of  processes. 

The  pathologic  physiology  of  excess  of  pancreatic  secretions  are  equally 
difficult  to  estimate  with  that  of  biliary.  Excessive  succus  pancreaticus  prac- 
tically prohibits  pancreatic  calculus.  (Enteron  and  colon)  excess  of  enteronic 
and  colonic  secretion  is  apparent  in  diarrhea,  in  fluid  evacuations.  Abnormal, 
excessive  intestinal  secretions  are  not  well  understood.  The  pathologic 
physiology  of  excessive  intestinal  secretion  rests  chiefly  on  the  kinds  of 
chemistry  of  food  and  bacteria  within  the  digestive  canal.  The  multiplica- 
tion of  bacteria  incites  the  intestine  to  extra  secretion.  The  abnormal  bac- 
teria process  may  continue  within  the  intestinal  lumen.  The  number  of 
bacterial  residence  usually  constitute  about  one-third  of  the  weight  of  the  dry 
fecal  masses.  It  is  evident  from  this  view  that  bacteria  are  a  necessary  part 
of  the  tractus  intestinalis  of  higher  organisms.  The  child's  tractus  intestinalis 
possesses  a  bacterial  flora  by  the  fourth  day  of  extrauterine  life.  Excessive 
colonic  secretion,  pathologic  physiology,  is  well  known  in  mucous  colitis,  or 
what  I  considered  better  termed,  secretion  neurosis  of  the  colon. 

(f)  (Stomach)  deficient  secretion  of  the  tractus  intestinalis  constitutes  a 
frequent  condition  of  pathological  physiology.  The  most  evidently  marked 
state  of  deficient  intestinal  secretion  is  constipation.  Deficient  secretion  of 
HC1,  the  most  significant  secretory  gastric  function  in  the  stomach,  may  exist, 
indicating  malignancy,  chronic  gastritis,  infectious  disease,  acute  functional 
disease,  presenting  a  wide  zone  of  pathologic  physiology.  Deficient  HC1  is 
especially  noted  in  gastric  carcinoma.  (Stomach)  deficient  secretion  HC1 
changes  the  bacterial  process,  as  normal  gastric  secretion  is  doubtless  antisep- 
tic. The  most  important  means  to  check  microbic  process  in  the  stomach  is 
continuous  movements  of  food  and  frequent  evacuations.  With  deficient 
HC1  the  bacteria  multiply  in  stagnating  stomach  contents  increasing  lactic 
acid,  which  favors  bacterial  growth.  Deficient  HC1  enhances  the  decomposi- 
tion of  albumen  in  the  enteron  and  colon.  Abundant  bacterial  decomposition 
from  deficient  HC1  produces  products  which  irritate  the  gastric  mucosa,  induc- 
ing pain,  colic  vomiting,  defective  appetite,  gas. 

(Duodenum).  The  business  segment  of  the  digestive  tract  is  the  enteron 
into  which  flows  the  succus  bilis  et  succus  pancreaticus.     Deficient  biliary 


PHYSIOLOGY   OF  TRACTUS  INTESTINALIS 


451 


ABDOMINAL  BRAIN  AND  CCELIAC  PLEXUS 


Fig.  115.  This  figure  presents  the  nerves  of  the  proximal  part  of  the  tractus  intestinalis, 
that  is,  the  nerve  plexuses  accompanying  the  branches  of  arteria  coeliaca.  1  and  2  abdominal 
brain  surrounding  the  coeliac  axis  drawn  from  dissected  specimen.  H.  Hepatic  plexus  on 
hepatic  artery.  S.  Splenic  plexus  on  splenic  artery.  Gt.  Gastric  plexus  on  gastric  artery. 
Rn.  Renal  artery  (left).  R.  Right  renal  artery  in  the  dissection  was  rich  in  ganglia.  Dg. 
diaphragmatic  artery  with  its  ganglion.  G.  S.  Great  splanchnic  nerve.  Ad.  Adrenal.  K. 
Kidney.  Pn.  Pneumogastric  (Lt  left).  Ep.  Right  and  Eps.  left  epiploica  artery.  St.  Stomach 
Py.  Pyloric  artery.  C.  Cholecyst.  Co.  Chole-dochus.  N.  Adrenal  nerves  (right,  10,  left,  10). 
The  arterial  branches  and  loops  of  the  coeliac  tripod  (as  well  as  that  of  the  renals)  with  their 
corresponding  nerve  plexuses  demonstrate  how  solidly  and  compactly  the  viscera  of  the 
proximal  abdomen  are  anastomosed,  connected  into  single  delicately  poised  system  with  the 
abdominal  brain  as  a  center.  Hence  local  reflexes,  as  hepatic  or  renal  calculus,  disturb  the 
accurate  physiologic  balance  in  stomach,  kidney,  spleen,  liver  and  pancreas.  Food  in  the 
duodenum  (or  HC1)  will  induce:  (1)  the  bile  to  flow;  (2)  the  succus  entericus  to  flow;  (3) 
the  duodenal  glands  (intestinal — especially  Brunner's)  to  flow;  (4)  secretion  to  flow — all 
from  the  same  duodenal  stimulant  (food  or  HC1),  presenting  a  delicately  poised  nervous 
apparatus. 


452  THE  ABDOMIXAL  AND  PELVIC  BRAIN 

secretion  may  manifest  itself  by  clay  colored  stools,  by  icterus,  by  calculus 
obstructing  biliary  flow.  Pathologic  physiology  in  deficient  biliary  secretion 
presents  a  frequent  and  an  extensive  range  of  action.  Deficient  biliary  secre- 
tion occurs  with  deficient  amounts  of  appropriate  food,  hence  the  necessity 
of  rational  dietetics.  Deficient  biliary  secretion  lays  the  foundation  for  the 
most  distressing  of  hepatic  diseases— hepatic  calculus.  The  deficient  hepatic 
secretion  induces  a  limited  quantity  of  bile  with  a  slow  stream  allowing  ample 
opportunity  for  crystallization  and  the  formation  of  biliary  concrements. 
The  hepatic  calculus  consists  chiefly  of  cholesterine  and  calcium  salts  of 
bilirubin.  Naunyn  has  demonstrated  that  the  quantity  of  cholesterine  and 
calcium  salts  of  bilirubin  are  independent  of  the  kinds  of  ingesta,  hence  to 
prevent  biliary  concrements  we  must  employ  visceral  drainage  to  maintain 
such  salts  in  mechanical  suspension  and  irrigate,  flood,  them  onward  by  powerful, 
large  biliary  streams.  For  dissolving  cholesterine  the  bile  possesses  power- 
ful agents  in  cholate,  sapo,  adeps.  Since  cholesterine  appears  in  the  bile  as 
crystal,  or  in  combination  with  desquamated  epithelial  cells,  the  powerful,  large 
biliary  stream  from  ample  visceral  drainage  will  flood,  irrigate,  the  precipi- 
tated collected  crystals  and  concrements  into  the  duodenum.  Deficient  biliary 
flow  is  liable  to  become  stagnant,  favoring  bacterial  growth  and  bile  channel 
infection  because  the  volume  of  bile  stream,  being  diminished,  does  not  excite 
the  biliary  channels  to  vigorous  peristalsis  and  consequent  defective  flushing 
of  the  bile  passages  occurs.  Deficient  biliary  secretion  is  accompanied  by  the 
pathologic  physiology  of  diminished  bile  stream;  stagnation  of  bile  from 
diminished  biliary  peristalsis;  defective  irrigation  of  the  biliary  passages;  the 
precipitation,  formation  of  cholesterine  and  calcium  and  bilirubin  crystals  or 
concrements;  infection  of  the  biliary  passages;  insufficient  quantity  of  bile 
for  digestion  (clay  colored  decomposed  stools);  icterus  from  obstruction  of 
bile  passages  and  changed  direction  of  bile  stream  calculus  in  the  biliary 
channels  may  produce  disease  only  when  infection  arises  or  the  calculus 
becomes  clamped  (pain,  colic).  Inflammation  (cholecystitis)  creates  violent 
peristalsis  of  the  biliary  channels  and  hence  projects  the  calculus  in  various 
directions  until  it  is  finally  impressed,  engaged,  whence  pain  and  colic. 

In  icterus  the  bile  with  its  coloring  material  becomes  transfused  through 
the  body,  in  the  blood  and  lymph— presenting  typical  pathologic  physiology. 
Icterus  depends  on  complete  closure  of  the  ductus  choledochus  communis  but 
it  may  depend  on  hepatitis.  For  the  origin  of  icterus  the  kind  of  disease  is 
less  significant  than  its  seat. 

Deficient  pancreatic  secretion  is  diagnosed  by  the  undigested  fat  in  the 
stools.  In  700  personal  autopsic  inspections  I  observed  but  one  complete 
failure  of  pancreatic  secretions.  This  subject  possessed  a  carcinomatous 
invasion  of  the  ductus  choledochus  and  ductus  pancreaticus,  producing  com- 
plete obstruction  of  both  ducts.  In  ten  weeks  the  patient  lost  113  pounds. 
The  biliary  passages  (exclusive  of  the  cholecyst)  were  dilated  seven  times  their 
original  caliber  and  the  ductus  pancreaticus  was  dilated  some  20  times  its 
original  caliber.  The  pancreas  possesses  two  exit  ducts,  patent  perhaps  in  60 
per  cent  of  subjects.  If  one  becomes  obstructed  the  other  acts  vicariously 
for  both. 


PHYSIOLOGY  OF  TRACTUS  INTESTINALIS  453 

In  the  above  cited  case  Santorini's  duct  no  doubt  conducted  succus  pan- 
creaticus  into  the  duodenum.  Deficient  secretion  from  the  pancreas  arises 
from  partial  and  complete  obstruction  of  its  ducts  by  calculus,  neoplasm,  or 
by  degeneration  of  the  organ. 

Deficient  secretion  in  the  enteron  is  not  understood.  Deficient  secretion 
in  the  colon  results  in  the  well  known  disease,  constipation.  The  central 
nervous  system,  as  well  as  the  abdominal  sympathetic,  is  influential  in  dimin- 
ishing secretion.  In  fact,  the  pure  results  of  constipation  are  preponder- 
ating, psychic  and  subjective.  The  assimilation  of  the  individual  constipation 
does  not  suffer  materially;  however,  defecation  is  laborious  and  the  care  for 
the  evacuation  and  anxiety  as  to  food  selection  increases  the  neurosis;  with 
the  evacuation  the  head  becomes  free,  the  voice  becomes  cheerful,  the 
effect  is  mainly  suggestive. 

(g)  Disproportionate  secretion  is  where  the  secretions  of  the  segments  of 
the  tractus  intestinalis  are  irregular,  non-uniform,  disordered.  When  such 
disordered  secretions  mingle,  fermentation  occurs  with  consequent  tympanitis 
meteorismus.  The  gastric  secretions  may  be  disproportionate,  resulting  in  dis- 
ordered digestion.  Biliary  secretion  may  be  excessive,  pancreatic  secretions 
deficient,  thus  making  secretions  disproportionate,  and  the  same  conditions 
may  occur  in  the  enteron  and  colon. 

(3.)      ABSORPTION  (EXCESSIVE,    DEFICIENT,   DISPROPORTIONATE). 

(h)  Excessive  absorption  of  the  digestive  tract  is  difficult  to  demonstrate. 
However,  it  is  conceivable  that  the  absorptive  apparatus  of  the  tractus  intes- 
tinalis might  work  excessively,  absorbing  substances  which  injure  the  system. 
Decomposing  ingesta,  bacterial  products,  toxines,  may  be  too  rapidly 
absorbed.     Excessive  absorption  induces  constipation. 

(i)  Deficient  absorption  in  the  tractus  intestinalis  is  not  infrequent.  We 
notice  this  factor  when  the  food  passes  per  rectum  undigested.  Excessive 
peristaltic  movements  may  be  so  rapid  that  insufficient  time  is  allowed  absorp- 
tion. Deficient  pancreatic  secretion  does  not  prepare  the  fats  sufficiently 
for  absorption — hence  deficient  absorption,  pathologic  physiology,  may  rest 
on  many  factors,  neurosis,  excessive  or  deficient  peristalsis,  unsuitable  ingesta, 
infection. 

(j)  Disproportionate  absorption  occurs  but  is  difficult  to  demonstrate  the 
non-uniform,  unequal,  disordered  absorption  of  the  three  segments — gastrium, 
enteron,  colon. 

4.       SENSATION  (EXCESSIVE,   DEFICIENT,   DISPROPORTIONATE). 

(k)  Excessive  gastric  sensation  (hyperesthesia  of  mucosa)  not  infre- 
quently arises.  The  healthy  subject  notices  the  digesive  organs  only  when 
hunger  arises  or  the  gastrium  becomes  excessively  occupied  with  ingesta  or 
gas ;  one  might  state  that  it  is  a  distinct  function  of  the  tractus  intestinalis  to 
manifest  hunger.  The  physical  condition  is  also  of  direct  influence.  Hunger 
and  distension  of  the  stomach  are  related  because  subjects  afflicted  with 
super  activity  manifest  hunger  shortly  after  ingesting  meat,  which  is  rapidly 


454  THE  ABDOMINAL  AND  PELVIC  BRAIN 

evacuated  through  the  pylorus,  leaving  an  empty  stomach  with  recurring  secre- 
tions. Hunger  and  appetites  do  not  always  correspond.  One  may  feel  hun- 
gry but  does  not  eat,  as  the  appetite  fails.  The  Scotch  poetry  tells  much  of 
a  story. 

Some  have  meat  but  cannot  eat, 

Some  can  eat  but  have  no  meat. 


X-RAY  OF  DUCTUS  BILIS  AND  DUCTUS  PAXCREATICUS 


Fig.  116.  Presents  the  relations  of  the  biliary  and  pancreatic  ducts.  These  ducts  are 
ensheathed  by  a  nodular  network,  or  anastomosing,  fenestrated  meshwork  of  nerves  ruling 
finely  poised  balanced  physiology  dominated  by  the  abdominal  brain. 

It  is  possible  that  activity  of  both  motion  and  secretion  induces  appetite 
which  has  a  wide  zone  of  pathologic  physiology.  In  excessive  sensation  or  gas- 
tric hyperesthesia  the  sensation  of  gastric  pressure  or  fullness  in  eating  arises 
sooner  than  it  does  in  the  healthy,  in  fact  sooner  than  the  stomach  becomes 
full.     Occasionally  one  meets  a  patient  who  on  taking  ingesta  experiences 


PHYSIOLOGY  OF  TRACTUS  INTESTINALIS  455 

gastric  pain — this  may  be  neuralgia,  superacidity,  ulceration,  carcinoma, 
pergastric  peritoneal  adhesions.  The  superacidity,  irritable  gastric  muscu- 
laris  may  experience  pain  from  direct  effects  on  the  sensitive  nerves,  i.  e., 
superacidity  induces  muscular  colic.  The  fearful  "gastric  crises"  in  tabes 
and  the  other  spinal  affections  is  founded  on  degeneration  and  irritation  of 
the  vagus.  It  is  well  known  that  certain  individuals  are  supersensitive  not 
only  in  general  but  as  special  organs,  e.  g.,  some  will  vomit  on  seeing  a  fly 
in  the  soup.  From  sensitive  stomachs  appear  to  arise  dizziness,  sensory 
waves,  neuralgia, anomalies  of  cardiac  innervation.  Also  unclear  functional 
disturbances — however  I  would  suggest  that  such  attributes  of  numerous 
disturbances  rather  belong  to  the  abdominal  brain.  The  innumerable  "gas- 
tric reflexes"  are  receptions,  reorganizations  and  emissions  of  the  abdominal 
brain.  Vomiting,  sooner  or  later  after  ingesta,  may  occur  from  hyperesthesia 
of  the  gastric  mucosa.  I  have  had  several  patients  with  excessive  sensation, 
or  hyperesthesia,  of  the  gastric  mucosa.  One  patient  vomited  shortly  after 
taking  food  for  fourteen  years.  Her  stomach  absorbed  sufficient  to  maintain 
a  fair  condition  of  flesh.  Another  vomited  for  two  years  almost  immediately 
after  eating.  Excessive  sensation  in  the  gastric  mucosa  presents  a  wide  zone 
of  pathologic  physiology  in  the  various  degrees  of  vomiting  during  gestation. 
Many  subjects  possess  an  extraordinary  delicacy  and  sensitiveness  in  regard 
to  the  stomach.  If  such  subjects  exercise  care  in  selection  of  food  and  pru- 
dence in  eating  they  remain  relatively  healthy.  This  pretended  and  acquired 
idiosyncrasy  is  annoyingly  manifest  in  practice  when  we  are  continually 
meeting  people  who  cannot  take  certain  kinds  of  food,  as  eggs,  milk,  graham 
bread,  fruits,  etc.,  etc.,  such  patients  cannot  live  in  an  ordinary  boarding  house. 
Either  by  heredity  or  chiefly  by  habit  the  employment  of  certain  kinds  of 
food  have  a  wide  range  of  pathologic  physiology.  The  psychical  state  per- 
haps plays  the  preponderating  role  of  idiosyncrasy  of  foods.  The  so-called 
nervous  dyspeptic  experiences  all  kinds  of  sensations  in  the  stomach.  There 
is  no  structural  change  in  the  stomach  to  correspond  to  all  the  functional 
manifestations — it  is  pathologic  physiology.  The  crawling  of  animals  within 
the  stomach  and  tractus  intestinalis  may  be  interpreted  as  ingesta  or  gas  pass- 
ing over  the  hyperesthetic  or  supersensitive  mucosa. 

(1)  Deficient  sensation  in  the  tractus  intestinalis  doubtless  explains  the 
so-called  sluggish  bowel,  the  constipation.  The  absorption  of  the  food  is 
insufficient.  It  is  not  uncommon  for  patients  to  tell  me  that  the  bowels  are 
dead,  no  feeling  in  them. 

(m)  Disproportionate  sensation  is  non-uniform,  irregularly  located  hyper- 
esthesia and  anesthesia  of  the  mucosa  in  the  different  segments  of  the  diges- 
tive tract — gastrium,  enteron,  colon.  In  sensation  of  the  tractus  intestinalis, 
excessive,  deficient  or  disproportionate,  there  is  no  relation  between  anomalies 
of  function  and  anatomic  structure.  Anomalies  of  function  may  present  no 
recognizable  anatomic  changes — it  is  simply  pathologic  physiology.  The 
gastric  mucosa  rapidly  changes  at  death,  hence  cautious  examinations  are 
required  in  autopsies.  As  regards  the  relations  between  the  kind  of  anatomic 
changes  and  functional  disturbances,  we  are  but  little  informed  by  any  inves- 
tigations. 


456 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS  NERVOSUS  IN  REGARD  TO  THE  TRACTUS 

INTESTINALIS. 

The  tractus  nervosus  influences  two  spheres,  viz. :  corporeal  and  mental. 
The  nervous  system  extends  to  the  deepest  and  most  profound  secrets  of  life 
— mental  and  physical,  hence,  it  possesses  the  highest  differentiation  of  all 
visceral  tracts.  The  functions  of  the  tractus  intestinalis  vary  within  a  wide 
zone  of  pathologic  physiology,  e.  g.,  many  subjects  pass  a  week  without 
defecation  or  subjects  may  practice  defecations  daily.  The  tractus  intesti- 
nalis is  preponderatiyigly  controlled  by  the  abdominal  sympathetic  or  nervus 
vasomotorius.     It  requires  a  decade  for  the  nervus  vasomotorius  to  establish 


DUODENUM   WITH  ITS  TWO  DUCTS— BILIARY  AND  PANCREATIC 

Fig.  117.  Illustrates  the  duodenum,  the  most  important  segment  of  the  tractus  intesti- 
nalis, receiving  the  ductus  bilis  and  ductus  pancreaticus.  The  nervous  system  controlling 
the  secretion  of  the  tractus  intestinalis  must  be  delicately  poised,  balanced,  as  the  secretions 
of  one  gland  (as  the  liver)  is  a  complement  of  the  secretion  of  another  gland  (as  the  pan- 
creas). The  succus  pancreaticus  multiplies  the  power  and  utility  of  the  bile  in  digestion  if 
the  two  glandular  secretions  become  mixed  immediately  on  entrance  into  the  duodenum. 

its  control,  its  more  independent  rule.  The  wild  and  disordered  peristalsis 
of  a  child  is  due  to  the  cerebrum  and  Auerbach's  ganglionic  plexus  not  being 
completely  balanced,  in  control.  A  child  is  frequently  subject  to  peristaltic 
unrest,  intestinal  invagination  (pathologic  physiology).  Frequently  not  long 
before  death  in  adults  the  cerebrum  and  Auerbach's  ganglionic  plexus  lose 
their  complete  balance  (especially  the  cerebrum  being  less  influential)  and 
the  invagination  of  death  arises.     I  have  observed  4  to  6-inch  invaginations  in 


PHYSIOLOGY   OF  TRACTUS  INTESTINALIS  457 

subjects — absolute  pathologic  physiology — no  pathologic  anatomy.  Though 
the  function  of  the  nervus  vasomotorius  is  beyond  the  control  of  the  will, 
digestion  proceeds  in  spite  of  us  or  while  we  sleep.  The  five  abdominal  vis- 
ceral tracts  (tractus  genitalis,  urinarius,  intestinalis,  lymphaticus,  vascularis) 
exist  in  an  exquisitively  balanced  or  poised  state,  hence,  the  so-called  reflexes, 
from  one  visceral  tract  to  another,  accomplished  through  the  nervus  vasomo- 
torius, exert  extensive  influence  in  producing  pathologic  physiology — yes 
many  conditions  of  pathologic  physiology  arise  in  different  visceral  tracts. 
The  essential  conditions  of  a  reflex  are:  (a)  an  intact  sensory  periphery 
(receiver);  (b)  an  intact  ganglion  cell — pelvic  or  abdominal  brain — (reorga- 
nized; (c)  an  intact  conducting  apparatus  (transmitter).  A  pure  reflex  con- 
sists of  a  sensation  transmitted  to  a  reorganizing  center  which  emits  it  over 
a  motor  apparatus. 

A  reflex  is  independent  of  will.  The  abdominal  viscera  are  not  only 
intimately  connected,  associated  by  means  of  the  tractus  vascularis,  tractus 
lymphaticus,  tractus  nervosus  but  especially  by  the  peritoneum.  Any  exces- 
sive irritation  in  any  one  of  the  exquisitively  poised  visceral  tracts  immedi- 
ately unbalances  the  others — at  first  producing  pathologic  physiology  and 
perhaps  later  pathologic  anatomy.  Hence  the  sensory  apparatus  in  each 
visceral  tract  is  significant.  The  reflex  from  one  visceral  tract  to  the  other 
disorders:  (a)  the  blood  circulation;  (b)  lymph  circulation;  (c)  absorp- 
tion; (d)  secretion;  (e)  peristalsis;  (f)  sensation.  E.  g.,  when  the  gesta- 
tion contents  distends  the  uterus,  uneven  expansion  stimulates,  irritates  the 
sensory  apparatus  of  the  uterus.  The  sensation  is  transmitted  over  the  plexus 
interiliacus  and  plexus  ovaricus  to  the  abdominal  brain  where  reorganization 
occurs  whence  the  stimulus  is  emitted  over  the  plexus  gastricus  to  the  gas- 
trium  with  end  results  of  excessive  gastric  peristalsis  and  vomiting.  Other 
abdominal  visceral  tracts  are  likewise  effected  by  this  uterine  reflex,  but  do 
not  manifest  such  prominent  symptoms  as  vomiting.  Vomiting  is  pathologic 
physiology.  Ordinary  function  as  gestation  will  induce  pathologic  physiology 
in  the  tractus  intestinalis  by:  (a)  reflexes;  (b)  robbing  it  of  considerable 
blood — the  extra  amount  required  for  the  tractus  genitalis  to  gestate  the  child ; 
(c)  instituting  indigestion  and  constipation,  from  limited  blood  supply. 
A  calculus  in  the  tractus  urinarius  (ureter)  will  produce  numerous  reflexes 
with  consequent  pathologic  physiology  in  the  several  abdominal  visceral 
tracts — viz. :  disordered  peristalsis,  absorption,  secretion,  sensation — not 
pathologic  anatomy. 

TREATMENT  OF  PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS  INTESTINALIS. 

Since  pathologic  physiology  is  the  zone  between  physiology  and  patho- 
logic anatomy  it  should  be  practically  amenable  to  treatment.  First  and 
foremost,  the  diagnosis  should  be  made  and  the  cause  removed,  as  a  ureteral 
calculus,  anal  fissure,  hepatic  calculus  or  any  point  of  visceral  or  dietetic 
irritation.  The  most  essential  feature  of  subjects  suffering  from  pathologic 
physiology  of  the  tractus  intestinalis  is  deficient  visceral  drainage.  The 
blood  is  excessively  waste-laden  from  insufficient  elimination.     The  secretions 


458 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


are  scanty.  The  urine  is  concentrated,  its  crystallized  salts  are  evident  to 
the  eye.  The  skin  is  dry  from  insufficient  perspiration.  Sleep  is  defective 
from  the  bathing  of  the  innumerable  ganglia  with  waste  laden  blood.  Con- 
stipation, deficient  urine,  limited  perspiration,  capricious  appetite  and 
insomnia  characterize  subjects  with  pathologic  physiology  of  the  tractus 
intestinalis.  For  many  years  I  have  applied  a  treatment  to  such  subjects 
which  I  term 

VISCERAL  DRAINAGE. 

Visceral  drainage  signifies  that  visceral  tracti  are  placed  at   maximum 
elimination  by  dietetics,  fluids,   appropriate  hygiene  and   habitat,   exercise. 


X-RAY  OF  DUCTUS  BILIS,  DUCTUS  PANCREATICUS  AND  ARTERIA  HEPATICA 

Fig.  118.  Illustrates  the  vast  nerve  supply  it  requires  to  ensheath  the  channels  of  the  liver 
and  pancreas  with  a  nodular  network,  a  fenestrated  meshwork,  of  nerve  plexuses.  The  trac- 
tus nervosus  of  the  tractus  intestinalis  is  solidly  and  compactly  anastomosed. 

The  waste  products  of  food  and  tissue  are  vigorously  sewered  before  new 
ones  are  imposed.  The  most  important  principle  in  internal  medication  is 
ample  visceral  drainage.  The  residual  products  of  food  and  tissue  should 
have  a  maximum  drainage  in  health.  I  suggest  that  ample  visceral  drainage 
may  be  executed  by  means  of :  (A)  fluids ;  (B)  food. 

(A.)  Visceral  drainage  by  fluids. 

The  most  effective  diuretic  is  water.     One  of  the  best  laxatives  is  water. 
One  of  the  best  stimulants  of  renal  epithelium  is  sodium  chloride  (}£  to  Y\ 


PHYSIOLOGY   OF  TRACTUS  INTESTINALIS  459 

physiologic  salt  solution).  Hence  I  administer  8  ounces  of  half  normal  salt 
solution  to  a  patient  six  times  daily,  2  hours  apart.  Note — NaCl  is  contra- 
indicated  in  parenchymatous  nephritis.  48  ounces  of  yi  normal  salt  solution 
efficiently  increases  the  drain  of  the  kidney,  it  sustains  in  mechanical  suspen- 
sion the  insoluble  uric  acid,  it  stimulates  other  matters,  it  aids  the  sodium, 
potassium  or  ammonium  salts  to  form  combination  with  uric  acid,  producing 
soluble  urates.  The  J4  normal  salt  solution  effectively  stimulates  the  peri- 
stalsis and  epithelium  of  the  tractus  intestinalis  inducing  secretions  which 
liquify  stool,  preventing  constipation. 

(B.)  Visceral  drainage  by  foods. 

The  great  functions  of  the  tractus  intestinalis — peristalsis,  absorption, 
secretion — are  produced  and  maintained  by  food.  To  drain  the  tractus  intes- 
tinalis foods  which  leave  an  indigestible  residue  only  are  appropriate. 
Rational  foods  must  contain  appropriate  salts  whose  bases  may  form  combi- 
nations which  are  soluble  as  sodium  and  potassium  combined  with  uric  acid 
and  urates  to  form  soluble  urates.  The  proper  foods  are:  cereals,  vegeta- 
bles, albuminates  (milk,  eggs),  mixed  foods. 

Meats  should  be  limited,  as  they  enhance  excessive  uric  acid  formation. 
In  order  to  stimulate  the  epithelium  of  the  digestive  tract  (sensation)  with 
consequent  increase  of  peristalsis,  absorption  and  secretion,  I  use  a  part  or 
multiple  of  an  alkaline  tablet  of  the  following  composition :  Cascara  sagrada 
GVgr.),  aloes  Q  gr.),  NaHC03  (gr.  1),  KHC03  (I  gr.),  MgS04  (2  gr.). 
The  tablet  is  used  as  follows:  One-sixth  to  one  tablet  (or  more,  as  required 
to  move  the  bowels  once  daily)  is  placed  on  the  tongue  before  meals  and 
followed  by  8  ounces  of  water  (better  hot).  At  10  a.  m.,  3  p.  m.,  and  bedtime 
\  to  1  tablet  is  placed  on  the  tongue  and  followed  by  a  glassful  of  any  fluid. 
In  combined  treatment  \  of  (NaCl)  the  sodium  chloride  tablet  containing 
11  grains  and  (g-  to  3)  alkaline*  tablets  are  placed  on  the  tongue  together 
every  2  hours  followed  by  a  glassful  of  fluid.  This  method  of  treatment 
furnishes  alkaline  bases  (sodium  and  potassium  and  ammonium)  to  combine 
with  the  free  uric  acid  in  the  urine,  producing  perfectly  soluble  alkaline 
urates  and  materially  diminishing  the  free  uric  acid  in  the  urine.  Besides 
the  alkaline  laxative  tablet  increases  the  peristalsis,  absorption  and  secretion 
of  the  intestinal  tract,  stimulating  the  sensation  of  the  mucosa  aiding  evacua- 
tion. I  have  termed  the  sodium  chloride  and  alkaline  laxative  method  the 
visceral  drainage  treatment.  The  alkaline  and  sodium  chloride  tablets  take 
place  of  the  so-called  mineral  waters.  I  continue  this  dietetic  treatment  of 
fluid  and  food  for  weeks,  months,  and  the  results  are  remarkably  successful 
in  pathologic  physiology.  The  urine  becomes  clarified  like  spring  water, 
and  increased  in  quantity.  The  tractus  intestinalis  becomes  freely  evacuated, 
regularly  daily.  The  blood  is  relieved  of  waste  laden  and  irritating  material. 
The  tractus  cutis  eliminates  freely,  and  the  skin  becomes  normal.  The 
appetite  increases.  The  sleep  becomes  improved.  The  patient  becomes 
hopeful,  natural  energy  returns.  The  sewers  of  the  body  are  well  drained 
and  flushed. 

*The  tablets  are  manufactured  by  Searle  and  Hereth  Company,  Chicago. 


CHAPTER   XXXIV. 

PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS  GENITALIS. 

"The  Soul  knows  only  Soul,  the  web  of  events  is  the  flowering  robe  in  which  she 
is  clothed." — Emerson. 

"Furnish  the  government  with  neither  a  kopek  nor  a  soldier." — Final  appeal  of  the 
Russian  Douma,  dissolved  by  the  czar,  July,  1906. 

For  over  a  decade  I  have  been  attempting  to  make  prominent  in  gyneco- 
logic teaching,  pathologic  physiology,  disordered  function,  rather  than  patho- 
logic anatomy,  changed  structure.  It  seems  to  me  that  disorder-functions  or 
pathologic  physiology  of  the  tractus  genitalis  impresses  itself  more  indelibly 
on  the  student's  and  practitioner's  mind  than  pathologic  anatomy.  Besides, 
in  gynecologic  practice  pathologic  physiology  occurs  tenfold  more  frequently 
in  the  genital  tract  than  pathologic  anatomy.  For  the  gynecologist  patho- 
logic physiology  presents  innumerable  views  of  practical  interest.  Pathologic 
physiology  teaches  that  the  circulation  of  an  organ  is  a  fundamental  factor 
in  comprehending  its  disease  and  administering  rational  treatment.  It  takes 
an  inventory  of  the  volume  of  blood  which  streams  through  the  organ  as  a 
fundamental  factor  in  comprehending  its  diseases  and  administering  rational 
treatment.  It  takes  an  inventory  of  the  volume  of  the  blood  which  streams 
through  the  organs  at  different  stages  and  conditions.  We  wrote  years  ago 
that  the  arteries  of  different  viscera  were  supplied  with  automatic  visceral 
ganglia,  and  we  christened  the  peculiar  nerve  nodes  found  in  the  walls  and 
adjacent  to  the  uterus,  oviducts  and  ovaries,  as  "Automatic  Menstrual 
Ganglia."  The  automatic  menstrual  ganglia  complicate  the  blood  supply 
of  the  tractus  genitalis  by  changing  its  volume  during  the  different  sexual 
phases.  In  pueritas  the  blood  stream  of  the  tractus  genitalis  is  quiescent  as 
well  as  its  parenchymatous  cells ;  in  pubertas  it  is  developing  as  well  as  pro- 
liferating parenchymatous  cells.  In  menstruation  the  blood  stream  is  active 
with  active  parenchymatous  cells.  In  the  puerperium  there  is  retrogression 
of  blood  stream  and  an  involution  of  parenchymatous  cells.  The  climac- 
terium is  the  opposite  of  pubertas — subsidence,  the  decrease  of  blood  volume 
and  parenchymatous  cells.  Senescence  is  a  repetition  of  pueritas — the  quies- 
cence of  the  genitals,  their  long  night  of  rest.  The  circulation  of  an  organ 
quotes  its  value  in  the  animal  economy.  It  rates  its  function.  Observe  the 
enormous  volume  of  blood  passing  through  the  kidney  or  pregnant  uterus  in 
a  minute. 

To  study  pathologic  physiology  of  any  visceral  tract  we  must  possess 
clear  views  as  to  its  physiology.  The  physiology  of  the  tractus  genitalis  is: 
(1)  ovulation;  (2)  peristalsis;  (3)  secretion;  (4)  absorption;  (5)  menstrua- 
tion; (6)  gestation;  (7)  sensation. 

460 


PHYSIOLOGY  OF  TRACT  US  GENITALIS  461 

(1)  On  account  of  the  numerous  theoretic  views  connected  with  ovulation 
and  lack  of  space  we  will  omit  the  general  discussion  on  the  pathologic 
physiology  of  ovulation.  It  is  well  known  that  ovulation  has  a  wide  physio- 
logic range.  We  do  not  know  the  life  of  an  ovum  or  corpus  luteum.  It  was 
once  supposed  that  a  corpus  luteum  was  a  sign  of  pregnancy  and  the  suppo- 
sition gained  legal  or  judicial  position.  We  know  that  this  is  an  error.  I 
have  found  two  corpora  lutea  on  one  ovary  of  a  lamb  which  had  not  been 
pregnant.  The  internal  secretion  of  the  ovary  is  important  and  chiefly  mani- 
fest by  marked  symptoms  on  removal  of  both  ovaries — neurosis,  accumulation 
of  panniculus  adiposus,  extra  growth  of  hair,  diminished  energy  and  ambition. 
These  symptoms  may  occur  in  women  possessing  both  ovaries,  hence,  we 
would  conclude  that  pathologic  physiology  of  ovarian  secretion  existed.  The 
sensation  of  the  ovary  occupies  a  wide  zone  of  pathologic  physiology  in  the 
mental  and  physical  being.  Forty  per  cent  of  women  visiting  my  office 
remark,  "I  have  pain  in  my  ovaries."  On  physical  examination  we  find  the 
following  conditions:  First  and  foremost  in  the  vast  majority  of  women  who 
complain  of  pain  in  the  ovaries,  palpation  of  the  ovaries  elicits  no  tenderness 
on  pressure.  However,  the  pain  of  such  women  is  located  bilaterally  in  the 
area  of  the  cutaneous  distribution  of  the  ileohypogastric  and  ileoinguinal 
nerves.  It  is  a  skin  hyperesthesia — a  cutaneous  neurosis.  The  bilateral  iliac 
region  of  cutaneous  hyperesthesia  corresponds  to  the  segmentation  or  somatic 
visceral  (ovarian)  area,  and  presents  a  frequent  varying  zone  of  sensory 
pathologic  physiology.  In  the  vast  majority  of  women  complaining  of  ovarian 
pain  no  disease  of  the  ovary  can  be  detected — it  is  cutaneous  hyperesthesia 
of  the  ileoinguinal  and  ileohypogastric  nerves. 

(2)    PERISTALSIS  (EXCESSIVE,   DEFICIENT,  DISPROPORTIONATE). 

(a)  Excessive  peristalsis  of  the  tractus  genitalis  (uterus  and  oviducts) 
may  occur  at  menstruation,  during  gestation,  parturition  by  the  presence  of 
myomata,  during  the  expulsion  of  blood  coagula,  placenta  during  congestion. 
The  phenomenon  of  peristalsis  in  the  uterus  and  oviduct  differs  from  the  form 
and  distribution  of  the  muscularis.  The  myometrium  during  gestation  is  in 
continual  peristalsis — uterine  unrest.  By  placing  the  hand  on  the  abdomen 
of  a  four-month  gestating  woman  one  can  feel  the  uterine  muscular  waves. 
The  gestating  uterus  is  always  prepared  for  an  abortion,  but  the  cervix,  the 
sentinel  on  guard,  checks  the  proceeding.  Fright  will  produce  such  violent, 
disordered  myometrical  peristalsis  as  to  break  through  the  guarding  cervix. 
Many  women  during  gestation  experience  considerable  pain  (supersensitive 
uterus)  from  excessive  uterine  peristalsis — it  is  pathologic  physiology. 
Uterine  peristalsis  may  be  sufficiently  excessive  to  rupture  the  myometrical 
wall.  The  "after-pains,"  puerperal  pains,  is  excessive  peristalsis  in  an 
infected  myometrium.  Frequently  the  severe  pelvic  pain  during  menstrua- 
tion is  excessive  uterine  and  oviductal  peristalsis  due  to  its  extramenstrual 
blood  supply.  It  is  chiefly  the  excessive  peristalsis  at  menstruation  that 
forces  many  women  to  assume  rest  in  bed,  for,  with  anatomic  rest  (maximum 
quietude  of  bones  and  voluntary  muscles)  and   physiologic  rest  (maximum 


462 


THE  ABDOMINAL  AXD  PELVIC  BRAIN 


quietude  of  visceral  muscles)  the  uterine  peristalsis  will  exist  at  a  minimum. 
Excessive  oviductal  peristalsis  may  produce  pain  of  varying  degrees.  In 
excessive  peristalsis  the  automatic  menstrual  ganglia  are  stimulated  by  extra 
quantities  of  blood  or  by  other  irritation. 


PELVIC  BRAIN  (ADULT) 


Fig  ^9.  Drawn  from  my  own  dissection.  A,  pelvic  brain.  In  this  case  it  is  a  gan- 
glionated  plexus  possessing  a  wide  meshwork.  Also  the  pelvic  brain  is  located  well  on  the 
£a!\n^  j  l£e  vlsceral  sacral  nerves  (pelvic  splanchnics)  are  markedly  elongated  ;  V,  vagina  ; 
B,  b  adder;  O,  oviduct;  Ut,  uterus;  Ur,  ureter;  R,  rectum  ;  P  L,  plexus  interiliacus  (left);  P 
K,  plexus  interiliacus  (right);  N,  sacral  ganglia;  Ur,  ureter;  5  L,  last  lumbar  nerve-  i  ii,  iii 
iv  sacral  nerves ;  5,  coccygeal  nerve.  Observe  that  the  great  vesical  nerve  (P)  arises  from 
a  loop  between  the  ii  and  iii  sacral  nerves.     G  S,  great  sciatic  nerve. 


PHYSIOLOGY   OF  TRACTUS  GENITALIS  463 

(b)  Deficient  peristalsis  of  the  tractus  genitalis  (uterus  and  oviducts)  is 
not  uncommon.  Uterine  inertia  is  an  example  known  to  every  obstetrician. 
Deficient  uterine  peristalsis  allows  hemorrhage  in  the  fourth  and  fifth  decades 
of  woman's  life.  Deficient  peristalsis  allows  extraglandular  secretion 
(leucorrhea). 

(c)  Disproportionate  peristalsis  is  disordered,  wild  muscular  movements 
in  different  segments  of  the  uterus  or  oviduct. 

(3)  SECRETION  (EXCESSIVE,   DEFICIENT,  DISPROPORTIONATE). 

(d)  Excessive  secretion  from  the  genital  tract,  pregnant  or  non-pregnant, 
has  an  extensive  range  and  varying  quantity.  The  excessive  secretion  zone 
in  the  tractus  genitalis  has  an  important  bearing  in  practice.  Typical  patho- 
logic physiology  may  be  observed  in  the  pregnant  woman  from  whose  uterus 
may  flow  several  ounces  of  white  mucus  daily — no  pathologic  anatomy  is 
detectable.  Excessive  uterine  secretion  is  a  common  gynecologic  matter. 
The  glands  may  not  be  embraced  sufficiently  firm  by  the  myometrium.  The 
automatic  menstrual  ganglia  are  diseased,  insufficiently  supplied  by  blood  or 
the  myometrium  is  degenerated.  Flaccid  uteri  secrete  excessively.  Exces- 
sive secretion  and  its  fluid  currents  allow  insufficient  time  for  localization  of 
the  ovum.  Excessive  uterine  secretion  is,  from  apt  bacterial  media,  liable  to 
become  infected.  During  excessive  secretion  physical  examination  frequently 
detects  no  palpable  pathologic  anatomy — merely  physiology  has  exceeded  its 
usual  bounds. 

(e)  Deficient  secretion  of  the  tractus  genitalis  is  not  so  manifest  as  its 
opposite.  The  mucosa  of  vagina  and  uterus  present  excessive  dryness,  des- 
iccation, practically  as  visceral  functions  are  executed  by  means  of  fluids, 
pathologic  physiology  is  in  evidence ;  dryness  and  abrasion  of  the  mucosa, 
local  irritation,  chafing,  local  bacterial  development,  dysparunia,  dysuria, 
defective  import  of  spermatozoa  and  export  of  ova  ending  in  sterility.  Defi- 
cient secretion  means  that  waste-laden  fluids  are  bathing  and  irritating  the 
thousands  of  lymph  channels  in  the  body.  Deficient  secretion  or  excessive 
dryness  of  the  genital  mucosa — pathologic  physiology  with  no  perceptible 
pathologic  anatomy — is  not  uncommon  in  gynecologic  practice.  Oily  appli- 
cations to  subjects  with  deficient  genital  secretion  may  be  required  for  pro- 
tection of  exposed  nerve  periphery,  as  abrasion,  fissure,  ulcers,  and  also  for 
relief. 

(f)  Disproportionate  secretion  may  occur  in  the  different  segments  of 
the  genital  tract,  unequal,  excessive,  deficient,  irregular. 

(4)    ABSORPTION  (EXCESSIVE,  DEFICIENT,  DISPROPORTIONATE). 

(g)  Excessive  absorption  presents  two  views,  namely,  a  dryness  of  the 
genital  mucosa  from  excessive  absorption  of  the  mucal  fluids.  This  resembles 
the  conditions  arising  in  deficient  secretion  of  the  genital  tract  (see  e).  Again 
the  mucosa  of  the  genital  tract  excessively  absorbs  deleterious  substances 
lying  on  its  mucosa — septic  or  toxic.  Excessive  absorption  in  the  genital 
tract,  pathologic  physiology,  resembles  excessive  absorption  and  conditions 


464 


THE  ABDOMIXAL  AXD  PELVIC  BRAIN 


in  other  localities,  as  the  absorption  of  poison  ivy,  lead,  arsenic,  among  art 
workers.  The  pathologic  physiology  possesses  a  wide  range,  for  some  experi- 
ence no  ill-effects  while  others  are  severely  or  even  fatally  ill  from  absorption 
of  same  substance  under  similar  conditions. 

(h)  Deficient  absorption  in  the    tractus  genitalis  produces  an  excessive 


Spiral  segment  (utero-ovarian  artery),  i,  2,  3,  4,  5.  6,  7-7,  8-8,  9,  10,  11,  12,  13,  14,  15. 
Straight  segment  abdominal  aorta,  16.     Common  iliac,  17,  and  internal  iliac,  18 


OIVISIOKS  OF  TNE  SPIRAL  SEGMENT 

Peliic  floor  segment,  1, 2, 3.  4. 
UleriCB  segment.  4,  5,  6. 
MM  segment, 


6,  7-9,  6-8,  9, 

4.  Orarian  segment, 
9,  10,  II,  12. 

5.  Round  ligament 
sepent,  13, 14, 15. 


IMPORTANT  LOCATIONS  II  THE  SPIRAL  SEGHEIT 
Arterio-ureteral  loop,  2.     Cervical 
loop,  2,  3,  4.     Distal  arte- 
rio-ureteral    crossing,    2. 
Rami    cervicis,     22. 
Rami    corporis,   23. 
Rami  fundi,  24.  Rami 
oviductus,  31,  32,  33. 

ElS31g.'H!«i  itariM 
zones  j  ctalral  iMgl- 
I'jJiDji  am,  <bi  lateral 
csmca!  ttriir,  tci  In* 
lis,  vi  1  unit*-' 
tapajat 


Chicago,  1902. 


At  ta«  aast  atrtta  IH  uteris  an 
iipctti  ii  sili,  alst  tie  ureters  »tt» 
red  lead  aid  stare*.    Tie  Sudan 

■as  X-raeed  11  Or.  Harrj  Pratt's  I 
flat  aid  Eitctra-Tatraattiti:  Laaao 
lorj,  iMbl)  aagiifiti  if  Or.  Wa.  t 
hiUik.  aid  tinned  as  a  atari  aj 
Hi-  Zae  0.  Klaaacr.  tn  artist 


Arterial  Circulation  of  the  Puerperal  Uterus. 


Four  Hours  Post  Partum.     Life  Size. 

Illustrating  the  Utero-Ovarian  Vascular  Circle  (the  Circle  of  Byron  Robinson). 

Fig.  120.     This  illustration  demonstrates    the  vast  amount    of   nervus  vasomotorius  it 
requires  to  ensheath  the  arteries  of  the  uterus. 


PHYSIOLOGY  OF  TRACTUS  GENITALIS  465 

discharge,  the  decomposition  of  which  lays  the  foundation  of  bacterial  multi- 
plication and  excoriation  of  mucosa  and  skin. 

(i)  Disproportionate  absorption  occurs  in  the  different  segments  of  the 
tractus  genitalis  and  presents  pathologic  physiology.  However,  lack  of  space 
makes  it  impractical  to  discuss  it. 

(5)    SENSATION  (EXCESSIVE,   DEFICIENT,   DISPROPORTIONATE). 

(j)  Excessive  sensation  in  the  tractus  genitalis  presents  a  wide  zone  of 
pathologic  physiology.  Vaginismus  is  the  extreme  type  of  genital  hyperes- 
thesia. The  introitus  vaginae  of  perhaps  fifty  per  cent  of  women  is  supersen- 
sitive. When  I  was  a  pupil  of  Mr.  Lawson  Tait  he  had  a  patient,  a  recently 
married  woman,  from  whom  the  husband  was  suing  for  divorce  as  her  genital 
hyperesthesia  was  so  excessive  that  coition  or  examination  was  intolerable. 
She  had  to  be  anesthetized  to  be  examined,  which  was  also  suggested  for 
impregnation  with  the  hope  that  gestation  would  relieve  the  condition. 
Supersensitiveness  of  the  pudendum  is  not  an  uncommon  matter  in  gyneco- 
logic practice  and  without  demonstrative  pathologic  anatomy.  The  patho- 
logic physiology  of  excessive  sensation  in  the  tractus  genitalis  has  a  wide 
range  of  variation  and  degree  of  intensity.  Some  subjects  may  be  afflicted 
with  excessive  sensation  in  the  pudendum  for  many  years.  The  excessive 
sensitive  genitals  may  be  manifest  in  the  uterus  or  ovaries.  A  small  number 
complain  of  tenderness  and  soreness  in  the  internal  genitals  which  cannot 
be  detected  as  pathologic  anatomy — simply  excessive  sensation.  The  gesta- 
ting  uterus  may  be  so  sensitive  that  it  disorders  adjacent  viscera  by  reflexes. 
The  treatment  of  subjects  with  excessive  genital  sensation  requires  unlimited 
time  with  continuous  patience. 

(k)  Deficient  sensation  of  the  tractus  genitalis  is  encountered.  With 
such  subjects  practically  no  organism  occurs  during  coition  to  which  they 
are  indifferent.     Practically  little  or  no  treatment  is  required. 

(1)  Disproportionate  sensation  in  the  genital  tract  is  irregular,  indefinite, 
disordered  sensation  arising  and  disappearing  in  its  different  segments  prac- 
tically without  reason  or  rhyme. 

(6)    MENSTRUATION  (EXCESSIVE,   DEFICIENT,   DISPROPORTIONATE). 

I  will  present  this  subject  through  a  clinical  patient.  Brief  remarks  on 
common  examples  of  pathologic  physiology  in  the  tractus  genitalis  will  suf- 
fice to  illustrate  and  suggest.  As  the  most  apt  subject  to  illustrate  pathologic 
physiology  in  the  tractus  genitalis  I  will  choose  that  of  menstruation. 

To  illustrate  the  value  of  pathologic  physiology  and  the  methods  of  teach- 
ing it  we  will  place  a  gynecologic  patient  before  a  student  to  elicit  clinical 
data  in  reference  to  menstruation  as  landmarks  for  diagnosis.  A  landmark 
is  a  point  for  consideration  physiologic,  anatomic,  pathologic.  To  teach 
gynecology  we  should  instruct  by  means  of  disordered  function  as  a  base. 
Menstruation  is  the  first  practical  function  of  the  genital  tract.  Hence  the 
student  asks  in  menstruation  four  questions,  namely:  (a)  How  old  were  you 
when  the  monthly  flow  began?     The  patient  may  answer:  eleven  (premature), 

30 


466  THE  ABDOMINAL  AXD  PELVIC  BRA1X 

fifteen  (normal),  or  nineteen  (delayed)  years  of  age.  This  answer  presents 
a  wide  range  of  beginning  of  the  menstrual  function.  Now,  the  girl  who 
begins  to  menstruate  at  eleven  generally  represents  pathologic  physiology, 
but  not  pathologic  anatomy.  For  example,  the  girl  who  begins  at  eleven 
(menstratio  precox)  will  in  the  majority  of  cases  menstruate  profusely  and 
prolonged.  She  will  experience  a  late  climacterium.  An  early  menstruation 
indicates  a  late  climacterium.  Though  one  can  palpate  practically  no 
pathologic  anatomy,  the  tractus  genitalis  is  prematurely  developed  at  eleven 
years  of  age,  premature  in  dimension  (nerves,  blood,  lymph,  parenchyma): 
and  function  (menstruation,  gestation).  The  blood  stream  to  the  genitals  is 
prematurely  excessive,  the  automatic  menstrual  ganglia  are  large  and  pre- 
maturely active.  Her  menstrual  life  is  accompanied  by  excessive  blood 
supply  and  hemorrhage,  disordered  function,  active  parenchymatous  cells, 
prolonged  reproductiveness.  It  is  pathologic  physiology,  exaggerated  func- 
tion, but  practically  not  pathologic  anatomy.  The  girl  who  begins  at  fifteen 
is  practically  normal  during  her  menstrual  life.  No  pathologic  anatomy  nor 
pathologic  physiology  is  manifest.  The  girl  who  begins  to  menstruate  at 
nineteen  (menstratio  retarda)  is  delayed  with  her  menstrual  function;  late 
menstrual  appearance  means  early  climacterium;  it  frequently  indicates 
amenorrhea  and  dysmenorrhea.  It  generally  means  defective  genital  blood 
supply  and  limited  parenchymatous  cellular  activity.  It  is  pathologic 
physiology,  disordered  function,  limited  productiveness,  but  frequently  no 
palpable  pathologic  anatomy  exists.  It  is  a  fact,  however,  that  in  some 
cases  atrophy  or  myometritis  is  palpable  pathologic  anatomy  and  should  not 
be  confused  with  subjects  possessing  pathologic  physiology. 

(b)  The  student  asks  the  patient:  Is  the  monthly  flow  regular?  The 
answer  may  be,  regular  or  irregular.  The  patient  with  irregular  menstrua- 
tion is  afflicted  with  pathologic  physiology  but  no  pathologic  anatomy  may 
be  detected.  It  may  be  stated,  however,  that  the  automatic  menstrual  gan- 
glia require  about  eighteen  months  of  vigorous  blood  supply  to  become  suffi- 
ciently strong  and  established  to  act  regularly  monthly.  The  same  condition 
exists  in  the  automatic  visceral  ganglia  (Auerbach's  and  Billroth-Meissner's) 
of  the  tractus  intestinalis  of  a  child. 

(c)  The  student,  thirdly,  asks  the  patient:  Is  the  monthly  flow  painful? 
The  answer  may  be,  yes  or  no.  A  normal  .menstruation  should  be  painless. 
Dysmenorrhea  or  painful  menstruation  is  pathologic  physiology,  disordered 
function,  but  frequently  no  pathologic  anatomy  can  be  detected.  At  men- 
struation the  blood  volume  in  the  tractus  intestinalis  rapidly  increases,  blood 
pressure  is  raised,  compressing  or  traumatizing  the  nerves  to  a  degree; 
limited   hematoma    may  occur   in  the  endometrium,  congestion  is  intense, 

TRANSVERSE  LONGITUDINAL  SECTION  OF  UTERUS 

Fig.  121.  This  illustration  presents  the  endometrium  (secretory  and  absorptive — glandu- 
lar— apparatus) ;  the  myometrium  (peristaltic  or  rhymic — muscular — apparatus) ;  the  peri- 
metrium (secretory,  absorptive — lymphatic — gliding  apparatus).  The  uterus  is  richly  sup- 
plied by  sensory  and  motor  nerves. 


Fig.  121.    Transverse  Longitudinal  Section  of  Uterus 


468  THE  ABDOMINAL  AND  PELVIC  BRAIN 

inciting  vigorous  and  disordered  peristalsis  of  the  uterus  and  oviducts.  In 
short  the  trauma  or  shock  of  menstruation  of  the  genital  tract  irritates  it  into 
a  state  of  pain.  It  is  a  state  of  pathologic  physiology,  disordered  function, 
but  no  pathologic  anatomy  may  be  palpable.     The  affliction  is  functional. 

(d)  The  student  finally  asks  the  patient:  How  many  days  does  the 
monthly  flow  continue?  The  answer  may  be,  two  to  eight  days.  Two  days 
is  deficient  (amenorrhea  or  oligemia);  four  days  is  normal,  eight  days  is 
excessive  (menorrhagia).  I  have  examined  scores  of  gynecologic  patients 
with  over  a  week's  flow,  menorrhagia,  but  in  many  of  them  no  pathologic 
anatomy  or  change  of  structure  could  be  detected.  It  is  typical  pathologic 
physiology,  disordered,  unusual  function.  The  subject  is  like  a  watch  with 
an  excessively  powerful  mainspring.  The  watch  has  no  detectable  pathologic 
anatomy,  no  change  of  structure.  The  mainspring,  the  automatic  ganglia, 
is  excessively  active.  The  organ  is  working  excessively,  the  watch  is  gaining 
time.  The  automatic  ganglia  are  prematurely  powerful,  the  watch  spring  is 
too  strong.  Menorrhagia  in  many  subjects  is  typical  pathologic  physiology. 
The  pathologic  anatomy,  if  it  exists,  is  too  subtle  for  us  to  detect.  The  adult 
life  of  the  tractus  genitalis  presents  an  excellent  field  for  study  and  teaching 
in  pathologic  physiology.  Its  several  periodic  functions,  its  changing  volume 
of  circulation,  the  limited  life  of  its  parenchymatous  cells  and  its  automatic 
menstrual  ganglia  afford  a  useful  field  for  study  and  development  of  patho- 
logic physiology. 

(7)    GESTATION*. 

Gestation  presents  many  phases  of  pathologic  physiology.  There  is 
the  typical  pathologic  physiology,  namely,  emesis,  albuminuria,  hypertrophy 
of  left  ventricle,  pigmentation,  capricious  appetite,  constipation,  increase  of 
panicular  adiposus,  the  peculiar  gait,  venous  engorgement  (edema),  excessive 
glandular  secretion,  osteomalacia.  The  vomiting  of  pregnancy  may  present 
a  vast  zone  from  slight  regurgitation  of  food  to  profound  anemia  due  to 
limited  nourishment — where  pathologic  physiology  alone  tells  the  tale.  The 
normal  physiologic  nerve  relations  between  the  tractus  genitalis  (uterus)  and 
tractus  intestinalis  (stomach)  have  become  disordered.  No  pathologic  anat- 
omy is  demonstrable.  Constipation  (pathologic  physiology)  is  liable  to  arise 
during  gestation  because  the  normal  physiologic  blood  supply  of  the  tractus 
intestinalis  is  robbed  to  supply  the  increasing  demand  of  the  gestating  genital 
tract.  The  albuminuria  of  pregnancy  is  doubtless  partially  due  to  pressure 
of  the  expanding  uterus  on  the  ureters  and  veins,  obstructing  venous  and 
urinal  flow.  The  normal  physiologic  relations  between  the  tractus  urinaria 
and  the  gestating  tractus  genitalis  have  become  projected  into  the  field  of 
pathologic  physiology.  Pathologic  anatomy  is  not  in  evidence  except  as 
ureteral  dilatation — a  secondary  matter.  A  comprehensive  view  of  pathologic 
physiology  aids  in  diagnosis  and  treatment.  It  will  impress  the  practitioners 
with  the  utility  of  visceral  drainage,  the  administration  of  ample  fluids  at 
regular  intervals  to  relieve  the  system  of  waste-laden  blood — irritating  sub- 
stances. Pathologic  physiology  teaches  us  to  restore  function  and  frequently 
pathologic  anatomy  will  take  care  of  itself. 


PHYSIOLOGY   OF   TRACTUS  GENITALIS 


469 


w^M 


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rfipa» 


PELVIC   BRAIN  IN  RELATION  TO  THE  NERVUS  VASOMOTORIUS 

Fig.  122.     General  view  of  the  nervus  vasomotoria  (sympathetic).     B.  Pelvic  brain.     H. 
Interilia  nerve  disc.     1  and  2.  Abdominal  brain. 


470  THE  ABDOMINAL  AND  PELVIC  BRAIN 

TREATMENT  OF  PATHOLOGIC   PHYSIOLOGY  OF  THE   TRACTUS  GENITALIS. 

Since  pathologic  physiology  is  the  zone  between  physiology  and  patho- 
logic anatomy,  it  should  be  amenable  to  treatment.  A  diagnosis  by  exclusion 
should  be  made.  It  must  be  remembered  that  in  the  physiology  the  entire 
six  abdominal  visceral  tracts  are  balanced  harmonious,  functionating  without 
friction — no  reflexes  dashing  hither  and  yon  disturbing  the  exquisitively  poised 
visceral  physiology.  In  the  treatment  of  pathologic  physiology  ol  the  tractus 
genitalis  it  should  be  remembered  that  the  genitals  are  not  vital  for  life,  but 
that  the  richly  nerve-supplied  genitals  dominate  the  mental  and  physical  exist- 
ence of  woman.  In  the  treatment  of  pathologic  physiology  there  are  the 
subjects  of  periodic  hyperemia,  congestion,  hemorrhages,  excessive  glandular 
secretions,  disturbed  sensation  (hyperesthesia).  First  and  foremost  in  the 
treatment  of  pathologic  physiology  of  the  tractus  genitalis,  the  adjacent 
visceral  tracts  must  be  regulated  to  normal  states  as  to  drainage,  but  espe- 
cially as  to  the  physiologic  condition  of  blood.  Frequently  by  producing  daily 
evacuation  of  the  digestive  tract  and  increasing  the  renal  secretion  by  ample 
fluids  the  pathologic  physiology  of  the  genital  tract  improves.  The  genitals 
should  be  examined  for  adherent  prepuce,  pudendal  fissure,  pruritus  pudendae, 
or  other  point  of  irritation.  The  other  five  abdominal  visceral  tracts  (urina- 
rius,  intestinalis,  vascularis,  lymphaticus,  nervosus)  should  be  examined  for 
points  of  visceral  irritation.  The  frequent  splanchnoptotic  condition  must 
be  studied  and  remedied. 

/.     VISCERAL    DRAIXAGE. 

For  many  years  I  have  applied  a  treatment  to  such  subjects  which  I  term 
visceral  drainage.  Visceral  drainage  signifies  that  visceral  tracts  are  placed 
at  maximum  elimination.  The  waste  product  of  food  and  tissue  are  vigor- 
ously sewered  before  new  ones  are  imposed.  The  most  important  principle 
in  internal  medication  is  ample  drainage  for  every  visceral  tract.  The  residual 
products  of  food  and  tissue  should  have  a  maximum  drainage  in  health.  I 
suggest  that  ample  visceral  drainage  may  be  executed  by  means  of:  (A) 
Fluids;  (B)  Food. 

(A)     Visceral  Drainage  by  Fluids. 

The  most  effective  diuretic  is  water.  One  of  the  best  laxatives  is  H20. 
One  of  the  best  stimulants  of  renal  epithelium  is  sodium  chloride  (one-half  to 
one-quarter  physiologic  salt  solution).  Hence  I  administer  eight  ounces  of 
half  normal  salt  solution  to  a  patient  six  times  a  day,  two  hours  apart. 
(Note. — Sodium  chloride  is  contraindicated  in  parenchymatous  nephritis.) 
Forty-eight  ounces  of  half  normal  salt  solution  daily  efficiently  increases  the 
drain  of  the  kidney.  It  maintains  in  mechanical  suspension  the  insoluble  uric 
acid;  it  stimulates  other  matters;  it  aids  the  sodium,  potassium,  or  ammonium 
salts  to  form  combination  with  the  uric  acid,  producing  soluble  urates.  The 
half  normal  salt  solution  effectively  stimulates  the  peristalsis  and  epithelium 
of  the  tractus  intestinalis,  inducing  secretions  which  liquefy  feces,  preventing 
constipation. 


PHYSIOLOGY   OF  TRACTUS  GENITALIS 
(B)    Visceral  Drainage  by  Foods. 


471 


The  great  functions  of  the  visceral  tract— peristalsis,  absorption,  secre- 
tion sensation— are  produced  and  maintained  by  fluids  and  foods.  To  drain 
the  tractus  genitalis  and  adjacent  visceral  tracts  which  should  be  excited  to 


ARTERIES  OF  PUERPERAL  UTERUS 

Fig  123.  Illustrates  the  arteries  of  a  puerperal  uterus  5  days  post  postum.  It is  a  half- 
tone-! so-called  bromine  photograph.  It  well  illustrates  the  enormous  amount  of  nerves  it 
would  require  to  ensheath  the  numerous  arteries  of  the  uterus.  The  uterus  was  injected  with 
red  lead  and  starch  and  X-rayed.     It  represents  excellently  the  author  s  circle. 

peristalsis,  foods  which  leave  an  indigestible  residue  only  are  appropriate 
All  visceral  tracts  must  be  stimulated  to  maximum  peristalsis,  secretion  and 
absorption  in  order  to  aid  that  of  the  tractus  genitalis.     Rational  foods  must 


472  THE  ABDOMINAL  AND  PELVIC  BRAIN 

contain  appropriate  salts  whose  bases  may  form  combinations  which  are  sol- 
uble, as  sodium,  potassium  and  ammonium  combined  with  uric  acid  and 
urates  to  form  soluble  urates.  The  proper  foods  are  cereals,  vegetables, 
albuminates  (milk,  eggs),  mixed  foods.  Meats  should  be  limited  as  they 
enhance  excessive  uric  acid  formation.  In  order  to  stimulate  the  epithelium 
(sensation)  of  the  digestive  and  urinary  tracts  with  consequent  increase  of 
peristalsis,  absorption  and  secretion  in  both  I  used  a  part  or  multiple  of  an 
alkaline  tablet  of  the  following  composition:  Cascara  sagrada  (o  grain), 
aloes  (3  grain),  sodium  carbonate  (1  grain),  potassium  carbonate  (3  grain), 
magnesium  sulphate  (2  grains).  The  tablet  is  used  as  follows:  One-sixth  to 
one  tablet  (or  more,  as  required  to  move  the  bowels  freely,  once  daily)  is 
placed  on  the  tongue  before  meals  and  followed  by  eight  ounces  of  water 
(better  hot).  Also  10  a.  m.  to  3  p.  m.,  and  at  bedtime  one-sixth  to  one  tablet 
is  placed  on  the  tongue  and  followed  by  a  glassful  of  any  fluid.  In  the  com- 
bined treatment  one-third  of  the  sodium  chloride  tablet  (containing  eleven 
grains)  and  one-sixth  to  three  alkaline  tablets  are  placed  on  the  tongue 
together  every  two  hours,  followed  by  a  glass  of  fluid.  The  eight  ounces  of 
fluid  may  be  milk,  buttermilk,  eggnog — nourishing  fluid.  This  method  of 
treatment  furnishes  alkaline  bases  (sodium,  potassium  and  ammonium)  to 
combine  with  the  free  uric  acid  in  the  urine,  producing  perfectly  soluble  alka- 
line urates  and  materially  diminishing  the  insoluble  free  uric  acid  in  the 
urine.  Besides,  the  alkaline  laxative  tablet  increases  the  peristalsis,  absorp- 
tion and  secretion  of  the  intestinal  tract,  stimulating  the  sensation  of  the 
mucosa — aiding  evacuation.  I  have  termed  the  sodium  chloride  and  alkaline 
laxative  method  the  visceral  drainage  treatment.  The  alkaline  and  sodium 
chloride  tablets  take  the  place  of  the  so-called  mineral  waters.  I  continue  this 
dietetic  treatment  for  weeks,  months,  and  the  results  are  remarkably  success- 
ful, especially  in  the  pathologic  physiology  of  the  visceral  tracts.  The  urine 
becomes  clarified  like  spring  water  and  increases  in  quantity.  The  tractus 
intestinalis  becomes  freely  evacuated,  regularly,  daily.  The  caliber  of  the 
tractus  vascularis  becomes  a  powerful  fluid  volume  to  carry  oxygen  and  food 
to  tissue,  while  the  effete  matter  and  waste  products  are  rapidly  swept  into 
the  sewer  channels.  The  blood  is  relieved  of  waste-laden  and  irritating 
material.  The  tractus  cutis  eliminates  freely  and  the  skin  becomes  normal. 
The  appetite  increases.  The  sleep  improves.  The  patient  becomes  hopeful, 
natural  energy  returns.  The  sewers  of  the  body  are  drained  and  flushed  to  a 
maximum. 

II.     VAGINAL  DOUCHE. 

(1)  The  kind  of  instrument  to  employ  is  a  fountain  syringe  of  fourteen- 
quart  capacity.  The  simplest  and  most  economic  vaginal  syringe  is  a  four- 
teen-quart  wooden  pail,  the  kind  generally  used  in  transporting  candy  or 
tobacco. 

(2)  The  location  of  the  syringe  should  be  four  feet  above  the  patient. 

(3)  The  quantity  of  fluid  administered  in  the  beginning  should  be  two 
quarts  for  patients  unaccustomed  to  its  use  and  four  quarts  to  those  accus- 


PHYSIOLOGY  OF  TRACTUS  GENITALIS 


473 


tomed  to  its  use.     The  quantity  should  be  increased  a  pint  at  each  administra- 
tion to  fourteen  quarts. 

(4)  The  temperature  of  the  douche  should  be  105°  in  the  beginning  and 
increased  one  degree  at  each  administration  until  it  is  as  hot  as  it  can  be 
borne  (115°  to  120c). 

(5)  The  duration  of  the  douche  should  be  ten  minutes  for  each  gallon. 


HISTOLOGY  OF  PELVIC  BRAIN 

Fig.  124.  A,  drawn  from  the  pelvic  brain  of  a  girl  seventeen  years  of  age.  The  ganglion 
cells  are  completely  developed.  B,  drawn  from  the  pelvic  brain  of  a  three  months'  normal 
gestation.  The  ganglion  cells  are  completely  developed.  Observe  the  enormous  mass  of 
connective  tissue  present.  C,  child  V/2  years  old.  A  nerve  process  courses  within  the  gan- 
glion. Few  and  small  ganglion  cells  incompletely  developed.  D,  girl  V/2  years  old.  A  nerve 
process  branches  and  reunites  itself  with  the  intercellular  substance.  E,  girl  6  years  old. 
The  ganglion  cells  are  presenting  development.     (Redrawn  after  Doctor  Sabura  Hashimoto.) 

(6)  The  time  to  administer  the  douche  is  in  the  evening  immediately 
before  retiring  and  in  the  morning  (after  which  the  patient  should  lie  hori- 
zontally for  forty-five  minutes). 

(7)  The  position  of  the  patient  should  be  lying  on  the  back. 

(8)  As  to  method  of  administering  the  douche  the  patient  should  lie  on  a 
sufficiently  inclined  plane  to  allow  the  returning  fluid  to  drain  into  a  vessel 


474  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(pail,  pan).  The  ironing  board,  wash-tub  or  board  resting  on  the  bath-tub 
serve  convenient  purposes.  The  douche  should  not  be  administered  in  the 
bed  (unless  ordered),  standing  or  sitting  postures  or  on  the  water-closet. 

(9)  As  to  ingredients  a  handful  of  sodium  chloride  and  a  teapoonful  of 
alum  should  be  added  to  each  gallon,  the  sodium  chloride  to  dissolve  the 
mucus  and  pus,  to  act  as  an  antiseptic  and  to  prevent  reaction,  while  the 
alum  is  to  astringe,  check  waste  secretions  and  harden  tissue. 

(10)  The  vaginal  tube  employed  in  administering  the  douche  should  be 
sterilized,  boiled,  and  every  patient  should  possess  her  own  vaginal  tube. 
The  most  useful  vaginal  tube  is  the  largest  that  can  be  conveniently  intro- 
duced or  the  one  that  distends  the  vaginal  forces  so  that  the  hot  fluids  will 
bathe  the  greatest  surface  area  of  the  proximal  or  upper  end  of  the  vagina. 

(11)  The  utility  of  a  vaginal  douche  is:  (a)  It  contracts  tissue  (muscle, 
elastic  and  connective);  (b)  it  contracts  vessels  (lymphatics,  veins  and 
arteries);  (c)  it  absorbs  exudates;  (d)  it  checks  secretion;  (e)  it  stimulates; 
(f)  it  relieves  pain;  (g)  it  cleanses;  (h)  it  checks  hemorrhage;  (i)  it  curtails 
inflammation;  (j)  it  drains  the  tractus  genitalis.  The  utility  of  the  vaginal 
douche  depends  on  the  quantity  of  fluid,  the  degree  of  temperature,  its  com- 
position, the  position  of  the  patient  during  administration,  and  on  systematic 
methods  of  use. 

(12)  Disinfectants  in  a  vaginal  douche  are  secondary  in  value  to  solvents 
of  mucus,  pus,  leucocytes. 

(13)  The  objects  to  accomplish  by  a  douche  are:  (a)  The  dissolving  of 
the  elements  in  the  discharge,  as  mucus,  pus  and  leucocytes;  (b)  the 
mechanical  removal  of  morbid  secretions,  accumulations  and  foreign  bodies; 
(c)  antisepsis;  (d)  diagnosis  (and  it  includes  number  11). 

(14)  The  requirements  of  a  douche;  (a)  It  should  be  nonirritating;  (b)  it 
should  be  a  clear  solution;  (c)  it  should  possess  solvent  powers  of  pus,  and 
especially  mucus;  (d)  it  should  be  continued  for  months;  (e)  omit  the  douche 
for  four  days  during  menstruation. 

(15)  A  vaginal  douche,  administered  according  to  the  above  directions, 
will  prove  to  be  of  therapeutic  value  in  the  treatment  of  pelvic  disease,  a 
prophylactic  agent  and  a  comfort  to  the  patient. 

(16)  The  vaginal  douche  is  contraindicated  in  subjects  with  oviductal 
gestation  or  acute  pyosalpinx,  as  it  is  liable  to  induce  rupture  of  the  oviductal 
wall,  abortion  or  leakage  of  pus  through  the  abdominal  oviductal  sphincter. 

III.     VAGINAL  T  AM  POX. 

(1)  The  composition  of  the  vaginal  tampon  consists  of  a  roll  of  medi- 
cated cotton  (hen-egg  size),  tied  to  a  twelve-inch  string,  placed  in  a  solution 
of  sixteen  ounces  of  glycerine  and  two  ounces  of  boracic  acid. 

TRACTUS  VASCULARIS  AND  TRACTUS  NERVOSUS  OF  THE  TRACTUS 

GENITALIS 

Fig.  125.  Illustrates  the  tractus  nervosus  of  the  genital  tract,  pregnant  5  months.  The 
utero-ovarian  vascular  circle  (circle  of  author)  is  ensheathed  by  a  rich  nodular,  fenestrated, 
anastomosing  nerve  plexus. 


Fig.  125.     Tractus  Vascularis  and  Tractus  Nervosus  of  the  Tractus  Genitalis 


476 


THE  ABDOMINAL  AXD  PELVIC  BRAIN 


(2)  The  duration  of  preparation  of  vaginal  tampon  should  be  to  lie  in  the 
boroglyceride  solution  forty-eight  hours  before  using. 

(3)  The  utility  of  the  vaginal  tampon  is:  (a)  It  is  hygroscopic;  (b)  it 
serves  as  a  mechanical  support;  (c)  it  contracts  tissue  (muscle,  elastic,  con- 
nective); (d)  it  contracts  vessels,  (lymphatics,  veins  and  arteries);  (e)  it  has- 
tens absorption  of  exudates;  (f)  it  checks  secretions;  (g)  it  stimulates;  (h)  it 
curtails  inflammation;  (i)  it  drains  the  pelvic  organs;  (j)  it  cleanses;  (k)  it 
dissolves  mucus,  pus  and  leucocytes.  The  utility  of  a  vaginal  tampon  depends 
on  its  composition,  the  quantity  employed,  the  duration  of  its  application 
and  on  systematic  method  of  use. 

(4)  The  methods  of  introduction  consist  in  placing  three  to  five  vaginal 
tampons  (with  or,  better,  without  a  speculum)  in  the  vaginal  fornices  in  the 
direction  of  least  resistance. 


PELVIC  BRAIN  (1,  2.) 
Fig.  126.     Dissected  from  a  subject  about  37  years  old. 

(5)  Disinfectants  in  a  vaginal  tampon  are  secondary  to  its  other  qualities, 
especially  that  of  hygroscopy. 

(6)  The  object  to  accomplish  by  a  vaginal  tampon  is:  Maximum 
hygroscopy,  dissolving  the  elements  in  the  discharge,  as  mucus,  pus,  leuco- 
cytes, the  mechanical  removal  of  morbid  secretions,  accumulation  and  foreign 
bodies,  diagnosis,  and  mechanical  support. 

(7)  The  diagnosis  is  aided  by  the  use  of  a  tampon  by  collecting  and  pre- 
serving the  uterine  discharge  (as  pus,  blood,  debris). 

(8)  The  requirements  of  a  vaginal  tampon  are :  (a)  It  should  be  nonirri- 
tating;  (b)  it  should  possess  hygroscopic  power;  ,(c)  it  should  be  a  solvent  of 
discharges  (mucus,  pus,  leucocytes,  blood) ;  (d)  it  should  aid  in  the  dissolv- 
ing  of   the  mechanical    removal    of   morbid   secretions,  accumulations,  and 


PHYSIOLOGY  OF  TRACTUS  GENITALIS 


477 


foreign  bodies;  (e)  it  should  be  aseptic  (not  necessarily  antiseptic);  (f)  it 
should  not  indelibly  stain  the  clothing  (this  is  objection  to  its  use  as,  for 
example,  ichthyol);  (g)  it  should  be  reasonably  economic. 

(9)  The  frequency  of  application  of  the  boroglyceride  vaginal  tampons 
should  be  in  general,  twice  weekly;  more  frequent  employment  may  cause 
irritation. 


SACRO-PUBIC  HERNIA 

Fig.  127.     This  illustration  demonstrates  how  the  ureters,  bladder  and  vagina  are  dis- 
torted and  consequently  how  the  accompanying  sympathetic  nerves  are  traumatized. 

(10)  The  time  to  apply  the  tampon  is  at  night  during  maximum  anatomic 
and  physiologic  rest. 

(11)  The  duration  the  tampon  may  remain  usefully  in  position  is  ten  to 
twenty-four  hours. 

(12)  There  are  no  special    contraindications   to  the  application  of  .the 
^aginal  tampon  (in  pelvic  disease). 


478  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(13)  The  boroglyceride  vaginal  tampon  may  be  beneficially  applied  in: 
(a)  inflammatory  pelvic  disease  (vaginitis,  endometritis,  myometritis,  endosal- 
pingitis,  myosalpingitis,  pelvic  peritonitis,  proctitis,  cystitis);  (b)  sacropubic 
hernia  (support  for  the  uterus,  cystocele  and  rectocele) ;  (c)  in  genital  ptosis 
it  depletes  the  lymphatics  and  veins. 

(14)  A  vaginal  tampon  applied  according  to  the  above  directions  will 
prove  to  be  of  therapeutic  value  in  the  treatment  of  pelvic  disease,  a  pro- 
phylactic agent  and  a  comfort  to  the  patient. 

IV.    HABITAT. 

The  value  of  fresh  air  was  never  realized  so  much  as  at  present.  Fresh 
cold  air  cures  pulmonary  and  other  tuberculoses.  The  success  of  the  sanitarium 
is  the  continued  use  of  fresh  (cold)  air.  The  subject  should  sleep  with  fresh 
cold  air  passing  through  an  open  window  space  of  three  by  three  feet.  It 
appears  to  be  demonstrated  that  cold  fresh  air  is  more  beneficial  than  warm 
fresh  air.  It  is  common  talk  among  people  that  one  winter  in  the  mountain 
is  worth  two  summers  for  the  consumptive.  The  curative  and  beneficial 
effect  of  cold  fresh  air  continually,  day  and  night,  for  the  family  must  be 
preached  in  season  and  out  of  season  by  physicians.  The  windows  should  be 
open  all  night.  Fresh  cold  air  is  one  of  the  best  therapeutic  agents  in  patho- 
logic physiology  of  the  tractus  genitalis. 

Exercise  is  an  essential  for  health.  Muscles  exercise  a  dominating  con- 
trol over  circulation  (blood  and  lymph).  The  abdominal  muscles  influence 
the  caliber  of  the  splanchnic  vessels.  They  exercise  an  essential  influence 
over  the  peristalsis,  secretion,  absorption  of  the  tractus  intestinalis,  unnarius, 
vascularis  and  genitalis.  The  muscles  massage  the  viscera,  enhancing  their 
function  and  the  rate  of  circulation.  In  the  uterus,  the  most  typical 
example,  it  is  prominently  marked  how  the  myometrium  controls  the  blood 
currents  like  living  ligatures.  The  habitat  that  furnishes  opportunity  for 
abundant  fresh  air  and  ample  exercise  is  the  one  that  affords  the  essential 
chances  for  recovery  of  pathologic  physiology  in  the  tractus  genitalis. 


CHAPTER   XXXV. 

PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS  URINARIUS. 

/  belong  to  the  great  church  that  holds  the  world  within  its  starlit  aisles;  that 
claims  the  great  and  gvod  of  every  race  and  clime;  that  finds  with  joy  the 
grain  of  gold  in  every  creed,  and  Hoods  with  light  and  love  the  germs  of 
good  in  every  soul. — R.  Ingcrsoll. 

The  rising  of  a  great  hope  is  like  the  rising  of  the  sun. — Charles  Kingslcy. 

The  physiology  or  function  of  the  tractus  urinarius  is:  (1)  peristalsis; 
(2)  secretion;  (3)  absorption;  (4)  sensation.  Pathologic  physiology  is  a 
deviation  from  the  usual  physiology  without,  however,  invading  the  field  of 
pathologic  anatomy.  The  tractus  urinarius  is  a  fertile  field  to  study  patho- 
logic physiology,  as  it  presents  a  wide  zone  of  varying  degrees,  especially 
since  recent  investigations  have  enriched  our  knowledge  of  renal  function. 
What  older  physicians  considered  pathologic  anatomy  in  renal  function  is 
now  believed  to  be  largely  pathologic  physiology.  The  zone  of  kidney 
function  is  a  continually  increasing  one.  In  the  study  of  pathologic  physi- 
ology of  the  tractus  urinarius  rational  and  comprehensive  views  of  the  renal 
viscus  will  be  entertained.  The  study  comprises:  (a)  the  condition  or  state 
of  the  kidney;  (b)  the  constituents  of  the  blood;  (c)  the  volume  of  blood 
that  streams  through  the  organ.  The  discussion  of  (a),  (b),  and  (c)  in  regard 
to  the  kidney  lends  a  comprehensive  view  to  the  student  in  making  a  diag- 
nosis of  the  living. 

We  will  here  consider  the  pathologic  physiology  of  the  urinary  tract  or 
Some  of  the  common  deviations  from  the  usual  physiology. 

(1)         PERISTALSIS    (EXCESSIVE,    DEFICIENT,    DISPROPORTIONATE). 

(a)  Excessive  peristalsis  may  occur  in  the  tractus  urinarius  from  numerous 
causes.  The  segment  of  the  urinary  tract  subject  to  peristalsis  is  the  ureter 
and  bladder.  The  ureter  is  an  independent  organ  resembling  the  heart, 
uterus,  stomach.  It  possesses  automatic  ureteral  ganglia  as  it  performs 
peristalsis  and  functionates  regardless  of  attitude  or  force  of  gravity. 
Excessive  peristalsis  is  most  liable  to  arise  from  excessive  drinking  of  fluids, 
ffrom  diabetes  or  polyuria  where  excessive  volumes  of  fluid  passed  through 
the  urinary  tract  in  limited  time.  The  most  marked  example  of  pathologic 
physiology  or  excessive  peristalsis  in  the  urinary  tract  arises  from  the  presence 
of  an  ureteral  calculus.  The  ureter  experiences  brusk,  vigorous,  violent, 
wild  and  disordered  movements  accompanied  by  excruciating  pain.  A  marked 
example  of  excessive  ureteral  peristalsis,  based,  however,  on  pathologic 
anatomy,  is  ureteritis  which  may  be  accompanied  by  excruciating  pain. 
From  experimentation  on  dogs  one  observes  that  the  peristalsis  of  the  ureter 
is  brisk,  vigorous,  resembling  that  of  the  heart,  uterus. 

479 


480 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


Fig.  128.     INTIMATE   RELATION  OF  THE  TRACTUS  GENITALIS  AND  TRACTUS 

URINARIUS 


PHYSIOLOGY   OF   TRACTUS   URINARIUS  481 

(b)  Deficient  peristalsis  of  the  urinary  tract  arises  in  connection  with 
limited  drinking  of  fluids,  limited  quantity  of  urine  (the  pressure  of  urine 
stimulates  the  ureteral  peristalsis) ;  a  limited  quantity  of  urine  accompanied 
by  a  limited  peristalsis  is  liable  to  be  followed  by  precipitation  of  crystals  and 
urinary  calculus.  However,  a  compensatory  action  arises  from  the  fact  that 
limited  urine  is  generally  concentrated  and  hence  is  apt  to  irritate  the  ureter, 
inducing  peristalsis.  It  is  probable  that  the  automatic  ureteral  ganglia, 
similar  to  the  automatic  intestinal  ganglia  (in  constipation)  may  become 
sluggish,  inducing  deficient  ureteral  peristalsis. 

(c)  Disproportionate  peristalsis  is  irregular,  unequal  peristalsis  in  different 
segments  of  the  tractus  urinarius,  as  bladder  or  ureter. 

(2)       SECRETION    (EXCESSIVE,    DEFICIENT,    DISPROPORTIONATE). 

(d)  Excessive  secretion  from  the  urinary  tract  is  observed  most  typically 
in  diabetes  mellitus,  insipidis  or  polyuria,  frequently  fields  of  simple  patho- 
logic physiology  where  no  pathologic  anatomy  can  be  detected. 

Excessive  renal  secretion  may  be  marked  in  change  of  temperature  from 
warm  to  cold  weather — a  difference  of  a  quart  of  urine  may  be  noted  enduring 
for  six  or  ten  days — simple  variation  of  renal  function.  The  function  of  the 
perspiratory  apparatus  has  experienced  a  deficient  secretion  relatively  equal 
to  the  pathologic  physiology  of  the  excessive  renal  action.  Cold,  contract- 
ing the  cutaneous  vessels,  forcing  the  blood  into  the  central  large  vessels, 
and  increasing  heart  action,  will  markedly  increase  renal  secretion.  Patho- 
logic physiology,  compensatory,  no  pathologic  anatomy;  it  is  a  form  of 
vicarious  physiology.  Sugar  may  appear  in  the  urine  for  some  time  (patho- 
logic physiology)  without  demonstrable  pathologic  anatomy — later,  however, 
indigested  fats  may  be  found  in  the  stools,  which  would  call  attention  to  the 
pancreas.  However,  the  pancreas  may  be  suffering  from  pathologic  physi- 
ology of  secretion  only  (excessive,  deficient,  or  disproportionate).  Pan- 
creatic secretion  may  be  insufficient  to  dissolve  the  fats.  So  that  even  at  the 
stage  of  diabetes,  pathologic  anatomy  may  not  yet  be  afoot.  Paresis 
(sluggishness)  of  the  renal  plexus  (ganglia)  may  allow  polyuria.  Constipation 
may  impose  increased  vicarious  duties  on  the  kidneys,  compelling  them  to 
eliminate  products  usually  eliminated  by  the  tractus  intestinalis.  We  know 
kidney  action  may  be  excessive,  that  is,  comprise  pathologic  physiology 
only,  for  we  not   infrequently  observe  one  kidney  successfully  accomplishing 


Fig.  128.  This  illustration  demonstrates  how  solidly  and  compactly  the  tractus  urinarius 
and  tractus  genitalis  are  anastomosed,  connected.  At  the  proximal  arterio-ureteral  crossing 
(11,  11)  the  ureter  and  ovarian  artery  are  solidly  and  firmly  anastomosed  by  the  nervus 
vasomotorius  (sympathetic).  Again  at  the  distal  arterio-ureteral  crossing  (2,  2)  a  similar 
but  more  extensive  anastomosis  occurs — hence  the  balanced  relationship  between  the 
tractus  urinarius  and  tractus  genitalis.  Every  practitioner  realizes  the  intimate  relation  of 
the  bladder  and  the  uterus,  e.  g.,  in  gestation,  through  the  nervus  vasomotorius.  This 
intimately  solid  anastomosis  between  the  two  visceral  tracts  by  means  of  abundant  nerve 
strands  aids  to  explain  the  vast  and  interdependent  pathologic  physiology  observed  in 
practice. 

31 


482 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


duplicate  work.  We  can  produce  excessive  secretion  of  urine  artificially  by 
administering  NaCl  in  ample  fluids.  Certain  foods,  as  water-melon,  produce 
temporary  excessive  renal  function,  with  certain  subjects,  apparently  exces- 


ILLUSTRATION  OF  THE  FEMALE  URINARY  TRACT 

H^Jn'JL129^  Thi;\sP?cimen  was  drawn  from  nature  from  my  own  dissection  by  the  aid  of 
distending  the  ureter's  veins  and  arteries  with  hardening  material.  The  ureter  (calyces 
It  wnrlnofUreter  ?w?er)  1S  ensheathed  with  a  nodular  fenestrated  web,  an  anastomosing 
?  Jr Z ?lu  s/mPathet£  "erves  especially  at  the  3  ureteral  isthmuses  (of  Byron  Robinson)  3, 
5  and  the  entrance  in  the  bladder.  Z,  Y,  3,  uretero-venous  triangle  (of  author).  The  nervus 
vasomotoria  richly  supplies  the  tractus  urinarius  and  manifests  itself  violently  during  the 
presence  of  a  moving  calculus  or  periodic  hydro-ureter,  or  ureteritis 


PHYSIOLOGY   OF    TRACTUS    URINARIUS  483 

sive  renal  secretion  (pathologic  physiology)  exists  for  years.     In  excessive 
renal  secretion  the  urinary  salts  may  be  excessive  or  deficient  or  vice  versa. 

(e)  Deficient  renal  secretion  may  be  noted  in  limited  drinking  of  fluids, 
in  restricted  diet  in  diarrhoea  (vicarious),  in  cold  weather,  in  debilitated 
heart,  in  fevers,  in  concentrated  foods  (flesh-eaters),  in  sedentary  habits  and 
in  numerous  nameless  conditions.  Deficient  renal  secretion  is,  from  my 
experience,  a  rather  common  condition.  Deficient  renal  secretion  may 
present  excessive  or  deficient  urinary  salts  or  vice  versa. 

In  certain  subjects  apparently  deficient  renal  secretions  exist  for  years. 
In  general,  deficient  renal  secretions  are  saturated  with  concentrated  urinal 
salts  which  may  irritate  the  mucosa  of  the  tractus  urinarius  sufficiently  to 
produce  pathologic  physiology.  Deficient  renal  secretion  may  lead  to 
uremia. 

(f)  Disproportionate  renal  secretion  is  irregular  in  different  segments  of 
the  kidney.  The  urine  may  be  excessive  and  the  salt  deficient  or  vice  versa. 
The  renal  glomeruli  may  secrete  deficient  or  excessive  fluids.  The 
uriniferous  tubules  may  secrete  deficient  or  excessive  salts. 

\Yhat  influence  has  the  disturbed  renal  secretion — the  pathologic  physi- 
ology— on  the  general  organism?  Manifold  injuries  may  occur.  The  con- 
tinual loss  in  albuminuria  is  exhausting.  The  insufficient  secretion  of  urinal 
constituents  from  the  blood  leads  finally  to  bodily  disturbance.  In  other 
words,  pathologic  physiology  in  renal  secretion  may  be  the  incipient  stage  of 
disease — pathologic  anatomy.  Disturbed  renal  secretion  may  be  accom- 
panied by  disease  in  different  organs — uremia,  which  represents  the  accumu- 
lated disturbances  on  various  organs. 

(3)       ABSORPTION    (EXCESSIVE,    DEFICIENT,    DISPROPORTIONATE). 

(g)  Excessive  absorption  of  the  tractus  renalis  would  constitute  extracting 
unusual  material  from  the  blood.  In  a  certain  sense,  excessive  renal  absorp- 
tion might  induce  excessive  secretion:  e.  g.,  on  urinalysis  albumen  may  be 
found  which  would  suggest  an  inquiry  as  to  the  quantity  of  egg  albumen  the 
subject  is  consuming.  Considerable  ingesta  of  albumen  may  lead  to  rich 
albuminuria.  Hence,  the  state  or  composition  of  the  blood  should  be  inves- 
tigated to  decide  the  amount  of  albuminuria.  If  there  be  excessive  sugar 
in  the  blood  and  sugar  being  absorbed  by  the  renal  apparatus  will  present 
excessive  secretion  of  sugar.  This  suggests  inquiry  into  the  quantity  of 
sugar  ingested. 

(h)  Deficient  absorption  would  indicate  that  the  renal  apparatus  does  not 
extract  from  the  blood  the  proper  amount  nor  the  proper  material.  The 
pathologic  physiology  has  a  wide  range  in  deficient  absorption,  for  some 
times  we  may  observe  an  adult  person  eliminating  8  or  10  ounces  of  urine 
daily. 

(i)  Disproportionate  absorption  constitutes  irregular  disordered  absorption 
of  the  different  segments  of  the  renal  apparatus,  as  the  glomeruli  and  the 
uriniferous  tubuies. 


484 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


Fig  130.    AN  ILLUSTRATION  OF  THE  ABDOMINAL  SYMPATHETIC  NERVE  OF 

THE  MALE,  ESPECIALLY  PRESENTING  THE  NERVES  OF 

THE  TRACTUS  URINARIUS 


PHYSIOLOGY    OF    TRACT  US    UR1NARIUS  485 

(4)      SENSATION    (EXCESSIVE,    DEFICIENT,     DISPROPORTIONATE). 

It  is  evident  on  watching  an  exposed  ureter  of  a  sleeping  dog  that  the 
sensation  of  the  mucosa  in  the  urinary  apparatus  is  of  vital  importance,  for 
each  and  every  time  that  a  certain  quantity  of  urine  collects  in  the  dog's 
ureteral  pelvis,  the  ureter  proper  executes  its  brusque,  vigorous  peristalsis 
with  remarkable  rapidity.  The  automatic  ureteral  ganglia  rule  the  ureteral 
peristalsis.  We  do  not  realize  the  exquisitively  poised  sensory  apparatus 
of  the  tractus  urinarius  until  some  catastrophy  occurs,  as  ureteral  calculus, 
to  apprise  us  of  the  wild,  disordered  peristalsis  and  excruciating  pain. 
Pathologic  physiology  of  sensation  in  the  tractus  urinarius  may  well  comprise 
excessive,  deficient  or  disproportionate  states  for  sensation  much  depends 
on  the  composition  of  the  urine  and  the  state  of  the  urinary  visera.  Inordi- 
nate meat  eaters  produce  concentrated,  irritating  urine,  exciting  excessive 
ureteral  peristalsis  with  consequent  pain — diluting  the  urine  relieves  the 
patient. 

In  excessive  sensation  of  the  tractus  urinarius  we  will  include  the  so- 
called  "irritated  bladder,"  because,  though  cystoscopy  has  lessened  the  actual 
number  of  irritable  bladders  by  eliminating  pathologic  anatomy,  it  can  not 
exclude  the  subject — pathologic  physiology.  Irritable  bladder  exists  without 
demonstrable  pathologic  anatomy.  The  subjective  symptoms  of  an  irritable 
or  excessively  sensitive  bladder  are  frequent  evacuations  (peristalsis).  The 
bladder  may  require  evacuations  several  times  an  hour.  There  is  an  increase 
in  frequency  and  intensity  in  the  desire  to  urinate — excessive  visceral  peri- 
stalsis. Irritable  bladder  may  persist  day  and  night.  The  desire  to  urinate 
may  be  so  intense  that  insufficient  time  is  allowed  to  prepare  the  dress  and 
hence  "wetting  of  the  clothing"  occurs.  Excessive  vesical  peristalsis, 
irritable  bladder  may  be  sufficient  to  cause  vesical  colic,  which  may  radiate, 
reflexly  to  the  tractus  intestinalis  or  genitalis,  disordering  the  function  of 
peristalsis,  absorption  or  secretion.  E.  g.,  the  patient  may  evacuate  feces 
and  urine  simultaneously — so-called  nervous  diarrhea. 

The  irritable  bladder  may  produce  cold  perspiration,  emesis,  chills,  and 
produce  mental  depression,  hypochondria.  The  main  objective  symptom 
of  irritable  bladder — pathologic  physiology  of  vesical  sensation  and  peristal- 
sis— is  hyperesthesia  which  manifests  itself  chiefly  in  the  trigone  where 
nerves  congregate.  The  neck  and  fundus  may  present  irritability.  The 
hyperesthesia    may    occur  as  an  increase  in  normal  sensibility  to  tensions  or 


Fig.  L30.  An  illustration  of  the  nervus  vasomotorius  (sympathetic)  drawn  from  a  speci- 
men which  I  secured  at  an  autopsy  through  the  courtesy  of  Professor  W.  A.  Evans.  The 
relation  of  the  nervus  vasomotorius  to  the  tractus  urinarius  is  evidently  intimate  and  abun- 
dant. The  network  of  nerves  on  the  arteria  renalis  and  ureter  are  apparent.  The  enormous 
supply  of  nerves  to  the  adrenal  is  remarkable — 7  in  number.  The  solid  anastomosis  of  the 
plexus  ovaricus  with  the  plexus  ureteris  is  noticeable,  where  the  vasa  ovarica  (spermatica) 
pass  ventral  to  the  ureter.  The  arteria  renalis  is  ensheathed  in  a  rich,  plexiform,  gangliated 
nerve  plexus.  I  dissected  this  specimen  under  alcohol,  and  the  nerve  relations  are  prac- 
tically correct.  The  artist,  Mr.  Zan  D.  Klopper,  followed  the  fresh  dissection  as  a  model. 
The  ureter  (calyces,  pelvis  and  ureter  proper)  is  dilated  bilaterally.  Even  the  3  ureteral 
isthmuses  (of  author)  are  dilated. 


486 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


as  abnormal  sensibility  to  pressure.     The  abnormal  sensibility  may  be  mani- 
fest on  the  presence  of  solid  feces  in  the  rectum,  digital  examination  or  on 
cystoscopy.     The  urine  may  present  nothing  abnormal  in  quantity   in  re-act- 
icn,  chemical  or  physical  characteristics;  no  hyperacidity,  no  excess  of  salts 
concentration  of  urine,  or  glycosuria.     What    causes  the    hyperesthesia    of 


Ar.  Vag- 
A.l.V. 

-A.&.V 


recJ'-sfte  aSria?hlnnH  PPly,t0t,he  tyaCtUS  urinari«s  »  best  remembered,  perhaps,  by 
TSHS^toSSSiL^JS?*?7'  f°r  ?!  nervUS  vasomotoria  accompanies  the  arteries 
ovarfca  (soermat^  fa)  artena  adrenalis  ;  (b)  arteria  renalis  ;  (c)  arteria 

art-",V^  (y)  arteria   uteris,  distal  (from   liac) ;  (z) 

clexus  Th  ,'ni  r  ,  /e,t  VeS1Cal  artenes>  each  of  which  is  accompanied  by  its  own  nerve 
plexus,     rtr    upper  part  of  illustration  is  from  corrosion  anatomy  ' 


PHYSIOLOGY   OF   TRACTUS    URINARIUS 


487 


the  vesical  wall — pathologic  physiology,  no  demonstrable  pathologic  anatomy 
— is  unknown.  Cystoscopic  examinations  and  autopsies  and  examinations 
demonstrate  that  in  irritable  bladder  no  pathologic  anatomy  may  exist  or  that 
a  condition  of  hyperemia  may  exist  in  the  bladder  wall.  The  subjects  of 
irritable  bladder  in  which  no  demonstrable  pathologic  anatomy  exists  are 
simply  nervous    in  character,   typical  pathologic  physiology.     The  subjects 


NERVES  OF  THE  TRACTUS  URINARIUS— CORROSION  ANATOMY 

Fig.  132.  This  specimen  presents  quite  faithfully  the  circulation,  the  kidney,  calyces  and 
pelvis.  The  two  renal  vascular  blades  I  present  opened  like  a  book.  The  corrosion  was  on 
the  left  kidney  and  the  larger  vascular  blade  is  the  ventral  one.  The  vasomotor  nerves 
accompanying  the  urinary  tract  may  be  estimated  by  the  fact  that  a  rich  plexiform  network 
of  nerves  ensheath  the  arteries,  the  calyces,  pelvis  and  ureter  proper.  When  the  renal  vas- 
cular blades  are  shut  like  a  book  their  thin  edges  come  in  contact,  but  do  not  anastomose. 
The  edges  of  the  vascular  blades  are  what  I  term  the  exsanguinated  renal  zone  of  Hyrtl,  who 
discovered  it  in  1868,  and  we,  at  present,  employ  it  for  incising  the  kidney  to  gain  entrance 
to  the  enterior  of  the  calyces  and  pelvis  with  minimum  hemorrhage.  This  specimen  presents 
excellently  the  capsular  artery — Cap.  A.  Think  of  the  vast  amount  of  pathologic  physiology 
which  could  be   created  by  disturbing  the  rich  sympathetic  nerve  supply  to  the  kidney. 


possessing  merely  hyperemia  of  the  vesical  wall  are  of  non-inflammatory  type 
or  non-detectable  inflammation.  The  irritable  bladder  is  influenced  especially 
by  two  factors,  viz. :  (a)  psychic  or  mental  disturbances ;  (b)  tendency  of  blood 
to  the  pelvic  organs  (bladder).  The  prognosis  of  irritable  bladder,  especially 
of  the  severe  type,  is  unfavorable — almost  every  case  I  have  observed  was 
or  has  been    practically  life  long.     The    treatment    is    hygienic,  dietetic — 


488 


THE  ABDOMIXAL  AND  PELVIC  BRAIN 


visceral  drainage,  preserving  maximum  state  and  contents  of  visceral  tracts. 
For  more  extensive  views  of  the  subject  of  irritable  bladder  see  the  excellent 
article  by  Hirsch,  Centralbllatt  f.  die  Grenzgebete  Medizin  u.  Chirurgie» 
Vol.  VIII,  Nos.  13  and  14. 


NERVUS  VASOMOTORIUS  OF  THE  TRACTUS  URINARIUS 
Fig.  133.  I  dissected  this  specimen  under  alcohol.  It  presents  excellently  the  solid  and 
compact  anastomosis  of  urinary  nerves  to  all  other  abdominal  vasomotor  nerves.  Observe 
the  solid  anastomosis  at  M  and  N.  The  reflexes  observed  in  practice  may  well  be  inter- 
preted by  this  illustration.  Note  the  multiple,  giant,  ganglia  accompanying  the  arteria 
renalis.     The  nerves  of  the  tractus  urinarius  presents  a  rich  field  in  pathologic  physiology. 

There  are  still  apparently  unsolved  problems  in  the  physiology  of  the 
tractus  urinarius  and  hence  multiple  unsolved  problems  in  the  pathologic 
physiology  of  this  important  visceral  tract.  For  example,  the  urine  (an  acid 
fluid)  is  derived  from  the  blood  (an  alkaline  fluid)  by  a  filtration  process. 
What  changes  the  urine  into  an  acid  fluid  from  the  blood,  an  alkaline  fluid? 
The  explanation  must  be  that  the  blood  is  practically  and  chemically  an 
acid  due  to  the  presence  of  bicarbonates  which  are  acid  salts. 


PHYSIOLOGY   OF   TRACTUS   URINARIUS 


489 


The  degree  of  the  acidity  of  the  urine  is  a  measure  of  the  degree  of  the 
acidity  of  the  blood.  The  acidity  of  both  urine  and  blood  is  due  to  acid 
phosphates  or  salts  of  phosphoric  acid  (H3PO4),  i.  e.,  salts  resembling  acid 
sodium  phosphate  (NaH2P04),  acid  calcium  phosphate  (CaHP04),  and  acid 
magnesium  phosphate  (MgHPO,),  which  may  assume  more  atoms  in  the 
bone. 


CORROSION  ANATOMY  (HYRTL'S  EXSANGUINATED  RENAL  ZONE) 

Fig.  134.  In  this  specimen  of  corrosion  anatomy  the  renal  vascular  blades  (ventral  and 
dorsal)  are  closed  like  a  book.  It  presents  (left  kidney)  on  the  margin  of  the  dorsal  lateral 
surface  the  exsanguinated  zone  of  Hyrtl — the  line  of  minimal  hemorrhage  for  corticle  renal 
incision.  A  rational  method  to  estimate  the  quantity  of  nerves  of  the  tractus  urinarius  is  to 
expose  the  number  and  dimension  of  the  arteries  and  other  tubular  ducts  which  are 
ensheathed  in  a  plexiform  network — a  fenestrated,  nodular,  neural  vagina  of  nerves.  The 
nervus  vasomotorius  rules  the  physiology  of  the  renal  apparatus.  Modern  investigation 
demonstrates  an  extensive  zone  of  pathologic  physiology  in  the  domain  of  the  kidney. 

"It  is,  therefore,  obvious  that  the  real  urinary  acidity  is  phosphoric  acid- 

VToJirnl    T„i,i'i,r,l     Mgv   9R      1QDR    1 


ity. 


t  is,  therefore,  obvious  that  the  real  urinary  acidity  is 
(Editorial,  New  York  Medical  Journal,  May  26,  1906.) 

TREATMENT    OF    PATHOLOGIC    PHYSIOLOGY   OF   THE    TRACTUS    URINARIUS. 


Since  pathologic  physiology  is  the  zone  between  physiology  and  patho- 
logic   anatomy  it  should  be  practically  amenable  to  treatment.     First  and 


490 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


foremost  the  diagnosis  should  be  made,  and  the  cause  removed,  as  ureteral 
calculus,  anal  fissure,  hepatic  calculus  or  any  point  of  general  visceral  irrita- 
tion.    The  most  general  essential  feature  of  a  subject  suffering  from  patho- 


Fig.  135.  This  specimen  I  dissected  with  extreme  care  under  alcohol,  and  the  artist,  Mr. 
Zan  D.  Klopper,  followed  the  dissection  as  a  model.  It  well  illustrates  the  nervus  vasomo- 
torius  in  relation  with  the  tractus  urinarius. 


logic  physiology  of  the  tractus  urinarius  is  deficient  visceral  drainage.  The 
blood  is  excessively  waste  laden  from  inefficient  elimination.  The  secretions 
are  scanty.     The  urine  is  concentrated,  its  crystallized  salts  are  evident  to 


PHYSIOLOGY   OF   TRACTUS   URINARIUS  491 

the  eye.  The  skin  is  dry  from  insufficient  perspiration,  sleep  is  defective 
from  bathing  of  the  innumerable  ganglia  with  waste  laden  blood.  Consti- 
pation, deficient  urine,  limited  perspiration,  capricious  appetite,  insomnia 
and  headache  characterize  subjects  with  pathologic  physiology  of  the 
tractus  urinarius. 

For  many  years  I  have  applied  a  treatment  to  such  subjects  which  I  term 
visceral  drainage.  Visceral  drainage  signifies  that  visceral  tracts  are  placed 
i  at  maximum  elimination.  The  waste  product  of  food  and  tissue  are  vigor- 
ously sewered  before  new  ones  are  imposed.  The  most  important  principle 
in  internal  medication  is  ample  visceral  drainage  for  every  visceral  tract. 
The  residual  products  of  food  and  tissue  should  have  a  maximum  drainage 
in  health.  I  suggest  that  ample  visceral  drainage  may  be  executed  by  means 
of:  (A) fluids;    (B)  food. 

(a),     visceral  drainage  by  fluids. 

The  most  effective  diuretic  is  water.  One  of  the  best  laxatives  is 
water.  One  of  the  best  stimulants  of  renal  epithelium  is  sodium  chloride 
(1-2  to  1-4  physiologic  salt  solution).  Hence  I  administer  eight  ounces  of 
half  normal  salt  solution  to  a  patient  six  times  a  day,  two  hours  apart. 
(Note — NaCl  is  contraindicated  in  parenchymatous  nephritis.)  48  ounces  of 
1-2  normal  salt  solution  daily  efficiently  increases  the  drain  of  the  kidney. 
It  maintains  in  mechanical  suspension  the  insoluble  uric  acid,  it  also  stimu- 
lates other  matters.  It  aids  the  sodium,  potassium  or  ammonium  salts  to 
form  combination  with  the  uric  acid  producing  soluble  urates. 

The  half  normal  salt  solution  effectively  stimulates  the  epithelium  of 
the  tractus  intestinalis,  inducing  secretions  which  liquefy  feces,  preventing 
constipation. 

(b).     visceral  drainage  by  foods. 

The  great  functions  of  the  tractus  urinarius — peristalsis,  absorption, 
secretion,  sensation — are  produced  and  maintained  by  fluids  and  food.  To 
drain  the  tractus  urinarius  the  adjacent  visceral  tracts  should  be  excited  to 
peristalsis,  hence  foods  which  leave  an  indigestible  residue  only  are  appro- 
priate, all  other  visceral  tracts  must  be  stimulated  to  maximum  peristalsis, 
secretion,  absorption  in  order  to  aid  that  of  the  tractus  urinarius.  Rational 
foods  must  contain  appropriate  salts  whose  bases  may  form  combinations 
which  are  soluble,  as  sodium,  potassium,  and  ammonium  combined  with  uric 
acid  and  urates  to  form  soluble  urates.  The  proper  foods  are  cereals,  veg- 
etables, albuminates  (milk,  eggs),  mixed  foods.  Meats  should  be  limited  as 
they  enhance  excessive  uric  acid  formation. 

In  order  to  stimulate  the  epithelium  (sensation)  of  the  digestive  and 
urinary  tract  with  consequent  increase  of  peristalsis,  absorption  and  secretion 
in  both,  I  use  a  part  or  multiple  of  an  alkaline  tablet  of  the  following  com- 
position: Cascara  Sagrada  (1-40  grain),  Aloes  (1-3  grain),  NaHC03  (1  grain), 
KHC03  (1-3  grain),  MgS04  (2  grains).     Tablet*  is  used  as  follows:  1-6  to  1 

*The  sodium  chloride  and  alkaline  tablets   are  manufactured   by   Searle   and   Hereth 
Co.,  Chicago. 


NERVUS  VASOMOTORIUS  OF  THE  TRACTUS  URIXARIUS 
(COXGEXITALLY  DISLOCATED) 

Fig.  136.  This  illustration  is  drawn  from  a  specimen  I  secured  at  an  autopsy.  The  right 
kidney  was  dislocated,  resting  on  the  right  common  iliac  artery,  with  its  pelvis  (P)  and  hilum 
facing  vemtralward.  The  adrenal  (Ad.)  remained  in  situ.  It  was  a  congenital  renal  disloca- 
tion, and  was  accompanied  with  congenital  malformations  in  the  sympathetic  nerve,  or 
nervus  vasomotorius.  1  and  2  is  the  abdominal  brain.  It  sends  five  branches  to  the 
adrenal  from  the  right  half  (2).  Though  the  sympathetic  system  is  malformed,  yet  the  prin- 
cipal rules  as  regards  the  sympathetic  ganglia  still  prevail,  viz.,  ganglia  exist  at  the  origin  of 
abdominal  visceral  vessels,  e.  g.,  3,  at  the  origin  of  the  inferior  mesenteric  artery ;  at  the 
root  of  the  renal  vessels,  HP  is  no  doubt  the  ganglion  originally  at  the  root  of  the  common 
iliacs  (coalesced).  In  this  specimen  the  right  ureter  was  5  inches'in  length,  while  the  left  was 
lll/2.  This  specimen  demonstrates  that  the  abdominal  brain  is  located  at  the  origin  of  the 
renal,  celiac,  and  superior  mesenteric  vessels — i.  e.,  it  is  a  vascular  brain  (cerebrum  vasomo- 
torius). The  solid  and  compact  anastomosis  of  the  nervus  vasomotorius  of  the  tractus 
urinarius  with  nerve  plexuses  of  all  other  abdominal  visceral  tracts  is  evident 


PHYSIOLOGY    OF    TRACTUS    URINARUJS  493 

tablet  (or  more,  as  required  to  move  the  bowels  freely,  once  daily)  is  placed  on 
the  tongue  before  meals  and  followed  by  8  ounces  of  water  (better  hot). 
Also  at  10  a.  m.,  3  p.  m.,  and  at  bedtime  1-6  to  1  tablet  is  placed  on  the 
tongue  and  followed  by  a  glassful  of  any  fluid.  In  the  combined  treatment, 
1-3  of  the  (NaCl)  sodium  chloride  tablet  (containing  11  grains)  and  (1-6 
to  3)  alkaline  tablets  are  placed  on  the  tongue  together  every  two  hours  and 
followed  by  a  glass  of  fluid.     The  six  glasses  of  fluid  may  be  milk,  butter- 


Fig.  137.  Illustrates  the  relation  of  the  spinal  nerves  to  the  tractus  urinarius,  especially 
to  the  plexus  lumbalis.  The  ureter  is  intimately  connected  with  the  genito-crural  nerve  (A) ; 
hence  the  pain  reflected  in  the  thigh  and  scrotum  in  ureteral  colic  and  other  ureteral  diseases. 
(2)  Ileo-inguinal  nerve. 

milk,  cream,  eggnog — nourishment.  This  method  of  treatment  furnishes 
alkaline  bases  (sodium,  potassium,  and  ammonium)  to  combine  with  the  free 
uric  acid  in  the  urine,  producing  perfectly  soluble  alkaline  urates  and 
materially  diminishing  the  insoluble  free  uric  acid  in  the  urine.  Besides,  the 
alkaline  laxative  tablet  increases  the  peristalsis,  absorption  and  secretion  of 
the  intestinal  tract,  stimulating  the  sensation  of  the  mucosa — aiding  evacu- 
ation. 

I  have  termed  the  sodium  chloride  and  alkaline  laxative  method  the  vis- 


494  THE  ABDOMINAL  AXD  PELVIC  BRAIX 

ceral  drainage  treatment.  The  alkaline  and  sodium  chloride  tablets  take  the 
place  of  so-called  mineral  waters.  I  continue  this  dietetic  treatment  of  fluids 
and  food  for  weeks,  months,  and  the  results  are  remarkably  successful, 
especially  in  pathologic  physiology  of  visceral  tracts.  The  urine  becomes 
clarified  like  spring  water  and  increased  in  quantity.  The  tractus  intestinalis 
becomes  freely  evacuated,  regularly,  daily.  The  blood  is  relieved  of  waste 
laden  and  irritating  material.  The  tractus  cutis  eliminates  freely  and  the 
skin  becomes  normal.  The  appetite  increases.  The  sleep  improves.  The 
patient  becomes  hopeful,  natural  energy  returns.  The  sewers  of  the  body 
are  drained  and  flushed  to  a  maximum. 

Had  space  permitted  it  might  have  enhanced  the  clearness  of  the 
above  subject  to  first  discuss  the  pathologic  physiology  of  the  tractus 
urinarius,  and,  second,  to  discuss  the  pathologic  physiology  of  the  con- 
tents of  the  tractus  urinarius. 


CHAPTER   XXXVI. 

PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS  NERVOSUS 

(ABDOMINALIS). 

The  man  who  builds  a  home  erects  a  temple — the  flame  upon  the  hearth  is  the 
sacred  fire.— Robert  Ingersoll,  American  (1844-1904). 

The  peritoneum  sheaths  and  lines. — Dr.  P.  T.  Burns. 

The  ideal  nervous  system  consists  of  a  ganglion  cell,  a  conducting  cord 
and  a  periphery,  i.  e.,  a  receiver,  a  transmitter  and  a  reorganizer.  This 
simple  view  of  the  structure  of  the  nervous  system  at  once  suggests  its  func- 
tion, viz.,  that  of  reception  (periphery  apparatus — skin,  mucosa),  transmission 
(conducting  apparatus — nerve  cords),  reorganization  (ganglion  cell — brain). 
The  nervous  apparatus  is  the  highest  and  most  perfect  of  known  organism. 
Mental  action  or  nerve  force,  the  most  subtle  of  all  forces,  depends  on  it. 
The  nervous  system  includes  the  most  profound  secrets  of  life  — it  is  the  climax 
of  organism.  First  and  foremost,  the  zone  of  the  physiology  of  the  tractus 
nervosus  is  not  exactly  denned — it  is  liberally  elastic.  Secondly,  the  patho- 
logic physiology  of  the  tractus  nervosus  possesses  an  expansive,  undefinable 
zone  before  established  pathologic  anatomy  can  be  recognized.  The  patho- 
logic physiology  of  the  tractus  nervosus  comprehends  the  fields  of  neuralgia, 
hyperesthesia,  anesthesia,  sensation,  motion,  melancholia,  hysteria,  neuras- 
thenia, with  innumerable  irritable  weaknesses  of  the  nervous  system. 
Absorption,  secretion  and  peristalsis  of  viscera  are  the  elements  or  means  by 
which  we  recognize  the  pathologic  physiology.  In  the  numerous  manifesta- 
tions of  symptoms  of  pathologic  physiology  of  the  tractus  nervosus  of  the 
abdomen  a  few  considerations  may  be  suggestive  and  helpful  in  practice. 
First  and  foremost,  many  subjects  are  not  perfect  physically  or  mentally. 
Such  subjects  are  prone  to  pathologic  physiology.  They  possess  inferior 
anatomy  and  physiology.  Structure  and  function  are  of  minimum  perfection. 
Their  nervous  system  is  not  stable.  We  should  consider  these  defections  or 
unstable  conditions  under  long-employed  or  established  terms,  associated 
with  which  has  grown  a  stately  literature,  as  stigma,  habitus,  asthenia  con- 
genita, heredity,  predisposition,  degeneracy. 

Nervous  persons  are  afflicted  with  pathologic  physiology.  Nervous  per- 
sons manifest  a  defective  resistence.  They  are  incapacitated  for  sustained 
effort.  Nervous  persons  present  premature  exhaustion  on  persistent  mental 
or  physical  effort.  The  reason  of  the  nervousness  is  the  anatomy  and 
physiology  of  the  tractus  nervosus  is  inferior,  its  structure  and  function  is 
deteriorated.  Their  nervous  system  is  irritable,  weak,  defective,  unstable, 
functionating  much  of  the  time  with  disorder  and  friction,  like  some  watches, 
which   maintain   incorrect   time.      Nervous   subjects  are   chiefly   congenital 

495 


496  THE  ABDOMINAL  AND  PELVIC  BRAIN 

unfortunates.  They  are  born  with  defects,  with  stigma,  a  habitus,  neuro- 
pathic predispositions — a  condition  which  tends  to  degeneracy  with  facility. 
Nervousness,  though  frequently  an  announcement  of  an  enfeebled  nervous 
system,  yet  it  may  be  evoked,  aggravated,  by  some  irritation  external  to  the 
nerve  apparatus.  Neurotic  spells  appear  with  as  much  mysticism  as  they 
disappear.  The  only  trace  is  the  memory  of  the  disordered  pathologic  physi- 
ology. There  is  doubtless  more  or  less  foundation,  for  these  inscrutable 
neurotic  conditions,  to  be  established  in  the  state  of  the  tractus  vascularis, 
congestion,  anemia.  The  tone  and  tension  of  the  abdominal  muscles  control 
the  abdominal  circulation.  Diseases  of  the  tractus  intestinalis  compromise 
the  tractus  nervosus  by  damaging  its  integrity — in  structure  and  function. 
One  of  the  best  terms  to  apply  to  subjects  who  are  persistently  afflicted  with 
pathologic  physiology  is  the  word  habitus,  e.  g.,  we  have  the  habitus  phthisi- 
cus,  habitus  splanchnopticus.  habitus  nervosus,  habitus  dyspepticus.  The 
ensemble  of  symptoms  associated  with  splanchnoptosia  may  well  be  termed 
habitus  splanchnopticus.  It  is  heredity  in  so  far  that  the  subject  possesses 
a  predisposition  and  the  main  defect  is  inferior  anatomy  and  physiology.  In 
the  habitus  splanchnopticus  there  is  the  gracile  skeleton,  the  elongated  flat 
thorax,  extensive  intercostal  space,  acute  epigastric  angle,  the  sacculated, 
pendulous  abdomen,  limited  muscularis  and  panniculus  adiposus,  the  labored 
respiration.  The  costa  fluctuans  decima  of  B.  Stiller,  the  peculiar  habitus 
in  form — presenting  evident  pathologic  physiology.  A  marked  factor  in 
pathologic  physiology  of  splanchnoptosia  is  the  changed  defective  circulation, 
venous  congestion.  Generally,  any  subject  with  a  "habitus"  possesses  an 
unstable  nervous  system.  The  dyspepsia  accompanying  the  habitus  splanch- 
nopticus is  perhaps  more  due  to  the  neuropathic  disposition  than  to  the 
splanchnoptosia,  hence  the  terms  dyspepsia  nervosa,  or  stigma  dyspepticum. 
The  habitus  neurasthenicus  presents  pathologic  physiology  of  the  tractus  ner- 
vosus— a  condition  of  exhaustion  or  weakness  of  the  nervous  system,  accom- 
panied by  physical  and  mental  efficiency.  Habitus  neurasthenicus  is  a  fatigue 
disease  of  the  nervous  system.  It  is  characterized  by  the  presence  of  motor, 
sensor}',  psychic  and  visceral  symptoms — all  fatigued,  tired,  exhausted.  This 
habitus  is  especially  characterized  by  weakness,  or  inefficiency  and  irritability 
of  the  tractus  nervosus.  The  physician  can  detect  spots  of  hyperesthesia, 
spinal  irritation,  fatigue  of  the  special  sense,  auditory  and  retinal  hyper- 
esthesia— all  pathologic  physiology,  no  pathologic  anatomy.  However,  if 
pathologic  anatomy  exists  in  the  body,  it  is  liable  to  intensify  the  pathologic 
physiology,  the  subject  of  habitus  neurasthenicus,  precipitating  storms  of 
neurotic  spells.  The  physician  can  detect  the  pathologic  physiology,  but  not 
pathologic  anatomy.  The  subject  is  afflicted  more  or  less  throughout  life 
with  pathologic  physiology.  When  such  subjects  maintain  additional  strains, 
as  gestation  and  the  care  of  growing  children,  pathologic  physiology  in  the 
tractus  nervosus  becomes  pronounced  and  frequent,  e.  g.,  the  habitus  neuras- 
thenicus may  be  in  abeyance,  quiescent,  for  a  long  period  of  time  when 
the  entrance  of  a  pelvic  disease,  a  myometritis,  salpingitis,  pelvic  peritenitis, 
may  initiate,  aggravate,  an  intense  neurotic  state.     It  is  not  due  merely  to  the 


PHYSIOLOGY    OF    TRACTUS   NERVOSUS  497 

so-called  reflexes,  but  because  the  habitus  neurasthenicus,  the  weak,  irritable 
nervous  system,  has  been  aggravated,  traumatized,  become  unbalanced, 
exhausted,  fatigued.  Its  inherent  vital  power  is  deficient  and  readily  passes 
into  a  state  of  pathologic  physiology. 

A  lesson  right  here  may  be  pointed  that  surgeons  should  operate  for  sur- 
gical indications  only,  not  for  function  indications.  First  and  foremost,  the 
gynecologist  must  learn  to  decide  by  an  analytic  exclusion  diagnosis  whether 
the  subject  has  a  habitus  neurasthenicus,  a  pelvic  disease,  or  the  two  com- 
bined. The  test  of  a  gynecologist  is  his  ability  to  diagnose  the  disease — not  to 
do  an  operation. 

The  exquisitely,  finely  balanced  nervous  system  of  woman  makes  it  liable 
to  imperfections  of  development — stigmata.  Such  a  perfect  organism  as  the 
tractus  nervosus  is  prone  to  disease.  The  intimate  and  profound  relation  of 
the  tractus  nervosus  to  the  tractus  genitalis  in  woman  demands  that  a  gynecol- 
ogist be  a  physician  of  comprehension,  or  knowledge,  understanding  the  vast 
fields  of  the  tractus  nervosus  and  tractus  genitalis,  as  well  as  their  profound 
relation. 

The  indiscreet  and  general  surgeon  announces  that  gynecology  is  "pass- 
ing," and  has  become  a  segment  of  general  surgery.  This  assertion  presents 
limited  comprehension.  Is  the  oculist  and  aurist  passing?  Is  the  dermatol- 
ogist, neurologist  and  laryngologist  passing?  Among  the  Germans,  the  most 
profoundly  learned  in  medicine,  specialists  are  progressively  increasing.  The 
fact  is  that  legitimate  gynecology,  like  all  other  specialities,  is  just  beginning. 
Gynecology  to-day  is  practically  as  broad  as  the  entire  medical  field  of  thirty 
years  ago.  The  gynecologist  must  comprehend  not  only  the  organs  in  his 
own  special  field  (tractus  genitalis),  but  also  the  adjacent  organs  involved  in 
practice  or  stimulating  gynecological  disease,  as  the  tractus  intestinalis,  trac- 
tus nervosus,  and  tractus  urinarius.  In  the  interest  of  the  patient,  no  special- 
ist can  be  limited  exactly  to  the  organs  of  his  own  specialty,  for  he  should 
study  the  organs  secondarily  afflicted  or  dependent  on  the  affections  of  the 
viscera  on  which  he  practices.  The  specialist  must  understand  the  anatomic 
and  pathologic  relations  of  specialized  organs  to  adjacent  territories,  as  vom- 
iting (tractus  intestinalis)  to  pregnancy  (tractus  genitalis),  as  albumin  (tractus 
urinarius)  to  pregnancy  (tractus  genitalis). 

The  more  intimate  changing  relations  of  associated  organs  in  structure 
and  function,  the  more  valuable  will  be  the  study  of  the  differential  diagnosis 
in  disease.  The  gynecologist  should  execute  all  necessary  technique  which 
will  enable  him  to  diagnose  and  treat  diseases,  dependent  on  or  associated  with 
the  tractus  genitalis — as  cystitis,  ureteritis,  splanchnoptosia,  mammary  dis- 
ease, constipation,  nephritis,  proctitis,  thyroid  disease.  The  borders  of  a 
specialty  cannot  be  marked  by  the  rim  of  a  circle,  but  by  the  diseases  de- 
pendent on  and  resulting  from  the  specialized  system  of  viscera.  Every 
special  science  gradually  unfolds  its  own  dependent  and  associated  relations. 

Gynecology  has  been  a  typical  example.  It  forced  a  divorce  from  general 
surgery,  to  which  it  never  will  return,  from  sheer  magnitude.  One  mind 
cannot  master  more  than  one  visceral  tract  with  its  relations.     The  unfolding 

32 


498  THE  ABDOMINAL  AND  PELVIC  BRAIN 

of  gynecology  has  increased  the  interest  and  usefulness  of  its  domain.  It 
has  shown  the  delicate  balance  and  relations  of  all  abdominal  viscera  on  the 
abdominal  sympathetic  brain.  Practically  all  progress,  new  ideas,  must 
come  from  specialists.  The  specialist  is  a  permanent  factor  in  medical  pro- 
gress, from  whom  will  practically  emanate  discoveries  and  rational  treatment. 
However,  the  present  and  future  specialist  will  not  be  limited  to  a  single 
visceral  tractus  for  the  diagnosis  and  therapy  of  his  independent  field,  but 
will  study  adjacent  or  remote  visceral  tracts  which  may  lend  aid  in  the  dif- 
ferential diagnosis  and  rational  treatment.  The  gynecologist  should  diagnose 
and  treat  all  diseases  primarily  or  secondarily,  dependent  on  the  life,  function 
and  pathologic  conditions  of  the  tractus  genitalis,  as  sacropubic  hernia, 
rectocele,  vesicocele,  splanchnoptosia;  dependent  on  rapid  and  frequent  gesta- 
tions (nephroptosia,  gastroptosia,  coloptosia,  hepaptosia — relaxed  abdominal 
walls).  The  rock  and  base  of  medical  practice  (special  or  general)  is  the 
diagnosis  which  enables  the  physician  to  employ  rational  treatment,  to  act 
for  the  best  interest  of  the  patient.  Large  numbers  of  women  with  marked 
splanchnoptosia  dependent  on  the  work  performed  by  the  tractus  genitalis, 
as  gestations,  come  to  the  gynecologist.  The  tractus  genitalis,  though  prim- 
arily the  basic  cause  of  splanchnoptosia,  itself  is  no  more  ill  than  the  tractus 
urinarius,  tractus  intestinalis,  or  the  relaxed  abdominal  walls.  It  is  the  duty 
of  the  gynecologist  to  treat  such  cases.  The  general  surgeon  is  no  more  an 
expert  in  special  departments  than  is  the  general  practitioner.  The  reason 
for  the  operation,  i.  e.,  the  diagnosis,  is  a  thousand  fold  more  expert  than  the 
mere  technique  of  surgical  procedure.  Predisposing  factors  to  pathologic 
physiology  in  the  tractus  nervosus  are  defective  nurtrition,  variations  of 
metabolism,  chlorosis,  anemia,  hemorrhages,  deficient  or  excessive  secretion, 
premature  senescence,  strained  physical  and  mental  efforts.  Heredity  trans- 
mits defects  which  are  the  foundation  for  aggravated  pathologic  physiology. 
When  the  subject  has  an  established  habitus,  as  habitus  splanchnopticus, 
habitus  neurasthenicus,  habitus  phthisicus,  and  predisposing  factors  become 
imposed  to,  the  subject  is  burdened  with  extreme  pathologic  physiology.  An 
excellent  example  of  artificial  habitus  is  the  numerous  stigmata  arising  from 
the  total  removal  of  ovaries  in  young  women,  which  condition  might  be 
termed  habitus  ovaricae  neurasthenicus.  The  young  woman  with  castrated 
ovaries  experiences  an  intense,  aggravated,  premature  climacterium — she  is 
suffering  from  pathologic  physiology  of  the  tractus  nervosus.  The  patient 
is  afflicted  with  flushing  (disturbed  circulatory  centre),  flashes  (disturbance  of 
caloric  centre),  perspiration  (disturbance  of  the  perspiratory  centre).  She  has 
depression,  melancholia,  excessive  panniculus  adiposus,  growths  of  hair.  In 
some  subjects  the  sensation  of  the  tractus  nervosus  of  the  abdomen  is  awry. 
Subjects  complain  of  animals  crawling  within  the  abdomen.  This  matter 
may  be  explained  by  supersensitiveness  or  hyperesthesia  of  the  mucosa  of 
the  tractus  intestinalis  from  gas  or  contents.  More  than  one  operation  has 
been  performed  for  such  condition.  It  may  be  incidentally  remarked  that 
it  requires  much  study  and  discreet  judgment  to  decide  neurosis  of  the  tractus 
nervosus  abdominalis  and  the  nervous  disturbances  produced  by  the  dominat- 


PHYSIOLOGY    OF    TRACTUS  NERVOSUS 


4S9 


ing  nerve-supplied  genital  tract — both  conditions  induce,  aggravate,  patho- 
logic physiology  in  the  abdominal  nerves,  e.  g.,  one  of  the  most  characteristic 
lesions  accompanying  the  habitus  neurasthenicus — producing  pathologic 
physiology — is  defective  development  of  the  tractus  genitalis.  I  think  among 
the  scores  of  women  I  have  examined  with  defective  development  of  the  gen- 
itals that  at  least  95  per  cent  were  neurotics  manifesting  pathologic  physiol- 
ogy of  the  tractus  nervosus.  Does  the  neurosis  precede  (congenital),  accom- 
pany the  defective  development  of  the  genitals  or  is  it  accidental  to  it?  The 
most  probable  view  is  that  it  is  congenital,  and  marks  an  ill  development  of 


Fig.  138.     Nerves  of  the  internal  genitals. 

the  organism.  The  habitus  neurasthenicus  or  habitus  hystericus  are  not  dis- 
eases of  the  genitals  but  of  the  nervous  system  with  an  hereditary  burden  and 
perhaps  an  acquired  burden.  These  conditions  required  vast  study  to  differ- 
entiate in  gynecologic  practice.  The  habitus  chlorosis  is  another  example  of 
a  disease  closely  associated  with  the  tractus  genitalis.  It  is  doubtless  hered- 
ity;  occurs  in  girls  from  fourteen  to  twenty-four  years  of  age,  i.  e.,  at  puberty 
or  the  developmental  stage;  is  accompanied  by  increased  panniculus  adiposus 


500  THE  ABDOMINAL  AND  PELVIC  BRAIN 

and  neurotic  symptoms.  Chlorosis  is  associated  with  defective  development 
of  the  genitals  in  75  per  cent  of  subjects.  Genital  functions  are  defective. 
The  nerves  governing  secretion  (ovarian)  are  perhaps  defective.  In  diagnos- 
ing pathologic  physiology  of  the  abdominal  nervous  system  it  is  well  to 
determine  the  etiology,  as  acquired  factors  enhance  conditions,  e.  g.,  the 
tractus  nervosus  of  a  pregnant  woman  is  more  irritable,  more  liable  to  patho- 
logic physiology,  than  the  non-pregnant.  The  nursing  woman  is  frequently 
in  a  state  of  pathologic  physiology. 

TREATMENT  OF  PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS  NERVOSUS. 

The  treatment  of  subjects  with  disturbances — pathologic  physiology — in 
the  abdominal  nerves  is  difficult  in  ordinary  practice  because  the  acquired 
factors  are  inseparably  associated  with  continuous  environments,  with  hab- 
itat. The  etiology  and  consequent  habitus  or  stigma  must  be  diagnosed  by 
careful  examination  in  individual  subjects.  The  reason  the  sanatorium  is  so 
successful  in  the  treatment  of  the  nervous  patients  is  the  patient  is  removed 
from  the  environments,  from  the  habitat,  in  which  the  disease  developed. 
The  provocative  or  aggravating  factors  must  be  generally  eliminated.  It 
may  be  constipation,  deficient  drinking  of  fluids,  the  ingesting  of  improper  con- 
centrated foods,  which  leave  insufficient  indigestible  residue  to  provoke  intes- 
tinal peristalsis.  It  may  be  sedentary  habits,  insufficient  exercise  or  deficient 
fresh  air.  It  may  be  excessive  work  and  worry,  insomnia.  In  the  subject 
with  the  habitus  neurasthenicus  I  am  in  general  opposed  to  the  so-called 
Mitchell  rest  cure.  The  neurasthenic  may  possess  fatigued  nerves  but  not 
fatigued  muscles.  I  attempt  to  treat  the  neurasthenic  by  maintaining  her  in 
the  fresh  air  and  muscular  activity  all  day.  In  the  subjects  I  administer 
active  visceral  drainage  and  coarse  foods  which  leave  a  large  undigestible 
residue.  She  is  improved  by  the  bicycle,  by  games  requiring  muscular 
activity,  rides  which  massage  the  viscera,  fresh  air,  appropriate  diet,  and 
ample  fluid  at  regular  intervals.  Some  neurasthenics  are  practically  unman- 
ageable. I  am  now  treating  a  woman  twenty-seven  years  of  age  who  has  lain 
in  bed  for  three  years.  She  says  her  nerves  could  not  stand  walking  in  the 
sunshine.  Physically  I  can  detect  no  pathologic  anatomy — simply  pathologic 
physiology.  By  forced  feeding  she  retains  ample  flesh.  During  the  last  six 
months,  by  all  kinds  of  persuasion,  we  succeeded  in  inducing  her  to  walk  one 
block  daily.  Maximum  visceral  drainage  and  appropriate  dietetics  maintains 
apparently  a  healthy  physique.  We  agree  with  Dr.  John  G.  Clark  that 
several  kinds  of  neurasthenics  exist.  The  gynecologist  meets  with  three  kinds 
of  neurasthenics,  viz.,  (a)  a  neurasthenic  of  congenital  origin — habitus  neuras- 
thenicus congenita — who  practice  almost  continually  genital  introspection 
where  the  physicians  can  not  detect  genital  pathologic  anatomy.  She  is 
constantly  occupied  by  views  regarding  genital  and  sexual  life.  The  treat- 
ment of  such  neuropathic  subjects  is  lifelong,  firm  discipline,  hygiene, 
dietetic,  fresh  air  for  twenty-four  hours  a  day,  ample  fluids,  physical  exercise, 
(b)  A  neurasthenic  with  coincident  visceral  lesion  but  each  entirely  independ- 
ent of  the  other,  as  may  occur  in  the  tractus  genitalis,  tractus  intestinalis, 


PHYSIOLOGY    OF   TRACTUS  NERFOSUS  501 

tractus  urinarius.  In  the  second  condition  the  additional  treatment  is  to 
remove  the  lesions  of  the  sole  visceral  tract;  (c)  a  third  kind  of  neurasthenic 
is  where  the  neurasthenia  is  dependent  on  an  organic,  visceral  lesion.  The 
tractus  nervosus  of  the  originally  predisposed,  neuropathic  subject  was  pro- 
voked, aggravated,  into  a  state  of  pathologic  physiology  by  the  organic  lesion. 
The  treatment  of  this  third  class  is  repair  of  the  organic  lesion  and  systematic 
visceral  drainage  by  means  of  fluids  and  foods. 

1.  Dietetic.  The  diet  of  neurotic  patients  should  be  regulated  under 
strict  discipline.  It  should  consist  of  cereals,  vegetables,  albuminates  (egg, 
milk),  and  limited  meals — mixed  diet.  The  high  spices,  cakes,  puddings, 
pies,  stimulants  should  be  eliminated. 

2.  Fluids.  Ample  at  regular  intervals — 8  ounces  every  two  hours  for 
at  least  six  times  daily.  This  forty-eight  ounces  of  fluids  daily  may  be 
nourishing  fluid — as,  milk,  buttermilk,  eggnog,  cereal  gruels. 

3.  Salt  rubs,  which  the  patient  administers  to  herself  once  or  twice 
daily,  at  stated  times  for  stated  duration. 

4.  Massage,  which  should  be  administered  as  much  as  possible  by  the 
patient  herself.  The  patient  can  be  taught  massage  of  the  abdominal  mus- 
cles, which  especially  benefits  the  abdominal  visceral  tracts. 

5.  Exercise  is  absolutely  necessary  for  health.  The  neurotic  patient 
continually  complains  of  tiredness  and  fatigue.  The  fatigue  belongs  to  the 
nerves.  It  is  not  muscle  fatigue,  hence  the  muscular  activity  should  be  vig- 
orously maintained  in  walking,  riding,  games — all  distracting  the  patient's 
attention  from  herself.  Muscular  exercise  influences  circulation  and  hence 
nourishment. 

6.  Fresh  air  should  be  continuous  day  and  night.  The  sleeping-window 
should  be  open  all  night.  The  window  of  the  day-room  should  be  continu- 
ously open.  Cold,  fresh  air  is  an  invaluable  therapeutic  agent  in  neurasthenic 
disturbances  and  tuberculoses. 

In  order  to  assist  the  foods  and  fluids  to  secure  maximum  visceral  drain- 
age I  place  on  the  tongue  every  two  hours  a  tablet  containing  3  grains  of 
sodium  chloride  (NaCl)  and  a  part  or  multiple  of  an  alkaline  tablet  [composed 
of  aloes  (\  gr.),  cascara  sagrada  (jj  gr.),  NaHC03  (1  gr.),  KHC03  (\  gr.), 
and  MgS04  (2  gr.),]  followed  by  8  ounces  of  fluid.  This  visceral  drainage 
method  I  followed  systematically  for  weeks  and  months,  resulting  in  success- 
ful maximum  visceral  drainage,  with  increased  nourishment,  improved  sleep. 
The  elimination  of  waste-laden  products  benefits  the  nervous  system — the 
pathologic  physiology  is  reduced  to  a  minimum  and  the  patient  recovers. 


CHAPTER  XXXVII. 

PATHOLOGIC    PHYSIOLOGY    OF    THE    TRACTUS    VASCULARIS. 

New  ideas  are  first  resented,  second  tolerated  and  finally  adopted. 
Men  may  come  and  men  may  go,  but  I  go  on  forever. — Tennyson's  Brook. 

The  functions  of  the  tractus  vascularis  are  peristalsis  (rhythm),  secretion, 
absorption,  sensation.  Its  object  is  to  transport  universal  nourishing  fluid, 
the  blood,  to  the  general  body.  In  pathologic  physiology  of  the  tractus  vas- 
cularis there  are  two  concomitant  factors  with  which  to  deal,  viz.,  (A)  the 
vascular  tract,  (B)  its  contents.  The  pathologic  physiology  of  the  tractus 
vascularis  and  its  contents  each  possess  a  wide  range. 

(A)    THE  VASCULAR    TRACT. 

The  tractus  vascularis  is  a  cylindrical  tube  possessing  the  form  of  a 
complete  circle,  with  localized  constrictions  (capillaries)  and  dilatations 
(heart-arteries,  and  veins).  This  vascular  canal  circulates  universal  fluid  tissue 
through  the  body.  It  has  a  dual  object  for  tissue,  viz.,  that  of  import  and 
export  service.  The  tractus  vascularis  will  become  of  vast  therapeutic  utility. 
Dr.  Bier,  a  man  of  forty-five  years  of  age,  Professor  of  Surgery  in  Bonn, 
Germany,  has  preached  for  years  the  value  of  artificial  congestion  in  the 
cure  of  disease.  Bier's  introduction  of  artificial  congestion  is  one  of  the  great- 
est contributions  to  medicine  of  the  present  century.  Lister's  contribution  was 
but  a  temporary  matter,  for  now  we  do  not  need  it,  as  we  have  learned  asep- 
sis. Bier's  method  will  always  be  useful  while  the  tractus  vascularis  remains. 
Men  may  come  and  men  may  go,  but  the  tractus  vascularis  goes  on  forever. 
Bier  suggests  to  the  profession  to  control  the  segments  of  the  tractus  vascu- 
laris and  its  contents  for  therapeutic  purposes. 

In  the  study  of  the  pathologic  physiology  of  the  hemogenous  tract  the 
exact  functions  must  be  held  in  view,  viz.,  peristalsis,  secretion,  absorption 
and  sensation.  The  condition  of  the  arterial  wall  and  the  diameter  of  the 
lumen  influence  the  flow  of  blood.  The  lumen  of  the  artery  is  controlled 
by  a  plexiform,  nodular,  fenestrated  network  of  nerves  and  ganglia  which 
ensheaths  the  artery.  The  lumen  of  the  artery  is  regulated  chiefly  by  reflexes 
that  arise  in  different  regions  of  the  body.  Stimulation  of  peripheral  nerve 
will  induce  generally  reflex  arterial  constriction  and  this  elevates  blood  pres- 
sure. All  nervous  impulses  from  the  heart  are  capable  of  governing  the  cali- 
bre of  arteries;  therefore,  the  degree  of  arterial  contraction  depends  chiefly 
on  the  nervous  impulses  which  they  receive.  For  the  theme  of  our  subject — 
the  abdominal  vessels — the  condition  of  the  numerous  abdominal  arteries 
innervated  by  the  splanchnic  nerves  is  of  significant  importance  in  regard  to 
maintaining  peripheral  resistance,  as  opposed  to  the  splanchnic  innervation. 

502 


PHYSIOLOGY  OF   TRACTUS  VASCULARIS  503 

A  brief  discussion  of  the  four  physiologic  functions  of  the  tractus  vascularis 
in  a  condition  of  pathologic  physiology  will  suffice  to  present  our  views. 

(1)    PERISTALSIS  (EXCESSIVE,   DEFICIENT,    DISPROPORTIONATE). 

(a)  Excessive  peristalsis  of  the  vascular  tract  is  a  common  occurrence  in 
life.  The  marble  paleness  of  fright  and  fear  present  excessive  contraction 
of  vessels.  The  cold  hands  and  feet  of  certain  persons  show  spasm  of  vessels. 
Excessive  cardiac  activity  is  frequently  noted.  The  cardiac  hypertrophies 
remain  long  in  the  stage  of  pathologic  physiology  as  compensatory  hypertro- 
phies. In  certain  renal  diseases  the  arterial  pressure  (arterial  peristalsis) 
increases  gradually  until  the  myocardium  has  attained  maximum  dimensions 
for  the  coronary  arteries  to  nourish.  Excessive  arterial  peristalsis  may  be 
an  indefinite  time  in  the  stage  of  pathologic  physiology,  as  cardiac  hypertro- 
phy, arterial  sclerosis,  nephritis.  It  is  during  the  stage  of  pathologic  physi- 
ology of  the  previous  immediately  noted  disease  that  medical  treatment  is  of 
practical  value  by  the  therapeutic  application  of  appropriate  dietetics,  fluids 
and  methods  of  living.  Vigorous  exercise  will  produce  excessive  peristalsis 
of  the  tractus  vascularis.  Not  infrequently  we  observe  the  abdominal  aorta 
maintaining  an  extraordinarily  vigorous  peristalsis  for  hours — in  fact,  it 
performs  with  such  vigor  that  the  inexperienced  may  diagnose  abdominal 
aneurism.  It  is  the  detection  of  excessive  vascular  peristalsis  (pathologic 
physiology)  in  its  incipient  stage  that  allows  ample  time  to  remove  the  causes 
of  disease  before  the  destructive  pathologic  anatomy  has  appeared  in  the  line 
that  renders  utility  to  medical  skill. 

Excessive  peristalsis  does  not  always  result  in  forcing  excessive  blood  to 
tissue,  because  the  arterial  pulse  caused  mainly  by  the  variation  of  pressure 
within  the  artery  and  the  results  of  intermittent  expulsion  of  blood  jets  from 
the  heart  may  become  so  deranged  and  disordered  that  blood  pressure  is  low. 
Arterial  blood  pressure  depends  on  the  amount  of  blood  forced  into  the 
arteries  by  the  heart  and  the  peripheral  arterial  resistance.  In  other  words, 
blood  pressure  depends  on  the  blood  volume,  rigidity  of  arterial  walls  and 
opportunity  of  escape.  Age  influences  blood  pressure.  We  note  pathologic 
physiology  of  the  tractus  vascularis  in  asphyxia.  Lead  colic  is  usually  associ- 
ated with  high  arterial  pressure  as  well  as  the  early  stages  of  peritonitis. 
Renal  disease  may  induce  high  arterial  pressure,  i.  e.,  an  excessive  vascular 
peristalsis. 

(b)  Deficient  peristalsis  of  the  vascular  system  is  frequently  encountered. 
The  myocardium  and  arterial  muscularis  may  be  diminutive.  The  vascular 
lumen  may  be  limited.  The  nervus  vasomotorius  may  be  inactive,  sluggish, 
of  minimum  power.  We  frequently  meet  the  small,  weak  cardiac  and  pulse 
action.  Deficient  arterial  peristalsis  results  in  deficient  tissue  nourishment 
and  cerebral  action.  We  frequently  meet  persons  with  deficient  vascular 
peristalsis  from  dietetic  and  habitat  errors.  The  subjects  consume  concen- 
trated foods  and  insufficient  fluids,  with  a  resulting  pulse  of  limited  volume 
and  power.  This  deficient  arterial  peristalsis  and  power  is  pathologic.  Physi- 
ology, however,  sooner  or  later  passes  from  the  incipient  stage  to  that  of 


504  THE  ABDOMINAL  AND  PELVIC  BRAIN 

established  pathologic  anatomy  by  continued  repetition.  The  employment  of 
ingesta,  which  leaves  a  large  indigestible  residue,  and  ample  fluids  at  regular 
intervals,  quickly  restores  a  pulse  of  full  volume,  i.  e.,  vigorous  arterial  peri- 
stalsis presenting  volume  and  power.  Errors  of  habitat,  inactivity,  sedentary, 
may  be  accompanied  by  deficient  arterial  peristalsis,  which  are  promptly 
improved  by  appropriate  exercise.  Deficient  peristalsis  of  the  heart  or 
inability  to  drive  the  congested  blood  through  the  lungs  will,  however,  act  as 
a   prophylaxis   against    pulmonary  tuberculosis  (it  is  a  cure  by  congestion). 

Extensive  areas  of  blood  vessel  dilatation  may  initiate  a  marked  fall  in 
arterial  pressure  and  slowing  of  circulation,  for  the  quantity  of  blood  is 
insufficient  to  occupy  the  entire  vascular  calibre  if  dilated.  General  vascular 
dilatation  may  result  from  general  loss  of  vascular  elasticity  and  consequent 
expansion  of  the  vessel  lumen.  A  general  loss  of  vascular  tonus  may  occur. 
If  the  splanchnic  vessels  lose  their  tonus  they  become  distended  with  blood, 
while  the  arteries,  especially  to  the  periphery,  skin,  become  but  partially 
depleted.  In  certain  autopsies  the  splanchnic  vessels  appear  so  extensively 
distended  with  blood  that  the  subject  seemed  as  if  he  had  bled  to  death  in  his 
own  abdominal  vessel.  Deficient  peristalsis  may  be  due  to  paresis  of  the 
vaso-motor  centre. 

(c)  Disproportionate  peristalsis  of  the  tractus  vascularis  consists  in  irreg- 
ularity of  action  in  different  segments  of  the  vascular  tract,  e.  g.,  the  blushing 
of  embarrassment,  the  flushing  of  the  climacterium,  is  local  dilatation  of  the 
vascular  tracts.  The  clubbed  fingers  of  the  subject  with  patent  foramen  ovale 
is  pathologic  physiology  of  the  blood  channel.  The  most  patent  example  of 
disproportionate  peristalsis  of  the  vascular  tract  is  the  defective  cardiac  valves 
— the  cardiac  insufficiency.  The  disproportionate  arterial  peristalsis  is  due 
to  abnormal  volumes  of  blood  in  local  segments  of  the  tractus  vascularis,  e.  g., 
in  insufficiency  of  the  aortic  valves  the  coronary  arteries  receive  excessive 
blood  and  produce  cardiac  hypertrophy.  The  volume  of  blood  remains  excess- 
ive in  the  heart  and  dependent  portions  of  the  body,  while  in  portions  of  the 
body  where  force  is  required  to  propel  the  blood,  it  is  deficient. 

Disproportionate  arterial  peristalsis  may  be  observed  during  gestation 
when  the  arteria  uterina  ovarica  sports  an  excessive  volume  of  blood.  During 
constipation  the  arteria  mesenterica  inferior  is  transporting  insufficient  blood, 
and  hence  inducing  insufficient  colonic  peristalsis  for  regular  fecal  evacuations. 
The  giant  hypertrophic  member  of  the  body  presents  an  excellent  example 
of  disproportionate  vascular  peristalsis.  The  mottled  surface  is  dispropor- 
tionate circulation.  Disproportionate  arterial  peristalsis  may  be  observed 
in  the  maximum  functions  of  the  several  visceral  organs,  e.  g.,  food  in  the 
gastrium  or  enteron  entices  extra  blood.  Extra  fluids  increase  especially  the 
activity  of  the  arteria  renalis.  Excessive,  deficient,  disproportionate  vascu- 
lar peristalsis  may  long  remain  in  the  field  of  pathologic  physiology^-func- 
tional  disease — allowing  ample  time  for  diagnosis  and  therapeutic  correction 
before  the  field  of  pathologic  anatomy — compromised  structure — is  reached. 


506  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(2)  SECRETION  (EXCESSIVE,  DEFICIENT,  DISPROPORTIONATE). 

(d)  Excessive  secretion  of  the  vascular  tract  may  be  observed  in  edema, 
ascites. 

(e)  Deficient  secretion  presents  few  practical  examples. 

(f)  Disproportionate  secretion  is  irregular  secretion  in  different  segments 
of  the  vascular  tract. 

(3)  ABSORPTION  (EXCESSIVE,   DEFICIENT,   DISPROPORTIONATE). 
(4)    SENSATION  (EXCESSIVE,   DEFICIENT,   DISPROPORTIONATE). 

(g)  Excessive  sensation  in  the  tractus  vascularis  indicates  an  irritable 
weakness  in  the  nervus  vasomotorius  (sympathetic),  which  rules  the  visceral 
tract.  It  appears  that  it  is  the  blood  in  the  vascular  lumen  which  incites 
peristalsis,  as  may  be  demonstrated  in  the  urine  and  the  ureter. 

The  excessive  sensation  in  the  vascular  tract  is  synonymous  with  the  state 
of  the  nervus  vasomotorius.  Some  vascular  tracts  with  inferior  anatomy  and 
physiology  execute  peristalsis  in  a  wild,  irregular,  violent,  disordered  manner 
on  slight  provocation ;  they  possess  excessive  sensation,  pathologic  physiol- 
ogy, or  are  afflicted  with  a  habitus  nervosus,  stigma  nervosus.  I  have 
observed  the  heart  executing  its  action  irregularly  and  120  per  minute  for 
weeks  with  no  demonstrable  pathologic  anatomy.  Such  a  person  possesses 
an  excessive  sensation  in  the  tractus  vascularis.  It  is  an  abnormal  function. 
The  excessive  beating  of  the  abdominal  aorta,  and  beating  in  various  parts  of 
the  body,  refers  to  excessive  sensation — hyperesthesia — in  the  tractus  vascu- 
laris. Blood  contents  in  the  tractus  vascularis  may  be  waste  laden,  irritat- 
ing, and  should  be  sewered  by  fluids. 

(h)  Deficient  sensation  in  the  vascular  tract  may  be  observed  in  the  slow, 
sluggish  pulse.  In  icterus  the  pulse  may  be  50;  sensation  isobtunded,  dulled, 
by  morbific  elements  bathing  the  innumerable  sympathetic  ganglia,  checking 
their  excitability. 

(i)  Disproportionate  sensation  is  irregular  sensation  in  different  segments 
of  the  tractus  vascularis.  Also  one  may  observe  in  certain  persons  local  con- 
gestions or  anemia.  Cold  feet  or  hands  produce  disproportionate  circulation 
in  the  body. 

TREATMENT  OF  PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS  VASCULARIS. 

The  treatment  of  pathologic  physiology  of  the  tractus  vascularis  consists 
in  correcting  the  deviation  of  its  functions  (which  are  peristalsis,  absorption, 
secretion  and  sensation). 

Since  pathologic  physiology  of  the  tractus  vascularis  lies  between  physi- 
ology and  pathologic  anatomy,  it  should  be  amenable  to  treatment.  First 
and  foremost,  a  diagnosis  should  be  made  and  cause  removed.  The  treatment 
is  accomplished  through:  (a)  Ample  fluids  administered  at  regular  intervals; 
(b)  appropriate  diet;  (c)  rational  habitat;  (d)  suitable  avocation.  Maximum 
elimination  or  visceral  drainage  is  the  rational  treatment. 


PHYSIOLOGY   OF  TRACTUS  VASCULARIS  507 

(a)  Visceral  Drainage  by  Fluids. — The  most  general  feature  of  a  patient 
suffering  from  pathologic  physiology  of  the  tractus  vascularis  is  deficient  vis- 
ceral drainage.  The  sovereign  remedy  is  water.  One  of  the  best  laxatives 
is  water.  The  most  rational  stimulant  to  the  renal  (and  intestinal)  epithe- 
ilium  is  sodium  chloride — common  salt  (one-fourth  to  one-half  normal  physi- 
ologic salt  solution).  I  administer  eight  ounces  of  one-fourth  to  one-half 
normal  salt  solution  every  two  hours  for  six  times  daily,  i.  e.,  three  pints 
daily.  (Note. — NaCl  is  contraindicated  in  parenchymatous  nephritis.)  The 
three  pints  of  normal  salt  solution  fill  the  lumen  of  the  artery  and  induce 
normal  reflexes.  The  pulse  becomes  a  full  volume.  The  powerful  arterial 
stream  sewers  the  body  of  waste  laden  blood  and  irritating  material.  The 
arteries  functionate  best  with  a  maximum  volume  of  blood.  Also  the  fluids 
induce  maximum  functions  of  adjacent  visceral  tracts — urinary,  intestinal, 
perspiratory.  Perfect  elimination  —  maximum  visceral  drainage — may  pre- 
vent arterial  sclerosis.  Maximum  visceral  drainage  maintains  in  mechanical 
suspension  the  insoluble  uric  acid  (preventing  the  formation  of  ureteral  cal- 
culus) and  the  cholesterine  (preventing  the  formation  of  hepatic  calculus). 

It  aids  the  sodium,  potassium  and  ammonium  salts  to  form  combinations 
with  uric  acid,  producing  soluble  urates.  The  eight  ounces  of  one-half  or 
one-quarter  normal  salt  solution  six  times  daily  stimulates  the  epithelium  of 
the  tractus  perspiratorius  (inducing  sweating)  and  the  epithelium  of  the  trac- 
tus intestinalis,  inducing  secretions  which  liquefy  feces,  preventing  constipa- 
tion. It  also  stimulates  the  epithelium  of  the  tractus  urinarius,  inducing 
increased  quantities  of  urine.  The  druggist  manufactures  for  me  sodium 
chloride,  tablets  of  twelve  grains  each,  from  which  I  can  employ  fragments 
or  multiples  in  the  treatment.* 

(b)  Visceral  Drainage  by  Foods. — The  great  functions  of  the  tractus 
vascularis — peristalsis,  absorption,  secretion,  sensation — are  produced  and 
maintained  by  fluids  and  foods.  To  drain  the  tractus  vascularis,  the  adjacent 
visceral  tracts  (intestinal,  urinary,  perspiratory)  should  be  excited  to  peri- 
stalsis. Hence,  for  the  intestinal  tract  foods  which  leave  an  indigestible 
residue  only  are  appropriate;  all  adjacent  visceral  tracts  must  be  stimulated 
to  maximum  peristalsis,  secretion,  absorption,  in  order  to  aid  that  of  the 
tractus  vascularis.  Rational  foods  must  contain  appropriate  salts  whose 
bases  may  form  combinations  which  are  soluble,  as  sodium,  potassium  and 
ammonium  combined  with  uric  acid  and  urates.  The  proper  foods  are 
cereals,  vegetables,  albuminates  (milk,  eggs),  mixed  foods.  Meats  should  be 
limited,  as  they  enhance  uric  acid  formation  and  waste-laden  blood. 

In  order  to  stimulate  the  epithelium  (sensation)  of  the  digestive,  urinary 
and  perspiratory  tracts,  with  consequent  increase  of  peristalsis,  absorption 
and  secretion,  I  use  a  part  or'a  multiple  of  an  alkaline  tablet  of  the  following 
composition:  Cascara  sagrada,  one-fortieth  of  a  grain;  aloes,  one-third  of  a 
grain;  NaHC03,  one  grain;  KHCO3,  one-half  grain;  MgS04  two  grains. 
The   tablet*   is    used   as    follows: 


*The  sodium  chloride  and   alkaline  tablets  are  manufactured  by  Searle  &  Hereth  Co., 
Chicago. 


508  THE  ABDOMINAL  AND  PELVIC  BRAIN 

One-sixth  to  one  tablet  (or  more  as  required  to  move  the  bowels  freely 
once  daily)  is  placed  on  the  tongue  before  meals  and  followed  by  eight 
ounces  of  water  (better  hot).  Also  at  10  a.  m.,  3  p.  m.  and  at  bedtime  one- 
sixth  to  one  tablet  is  placed  on  the  tongue  and  followed  by  a  glassful  of  any 
fluid  (buttermilk  is  excellent). 

The  Combined  Treatment  {Sodium  Chloride  mid  Alkaline  Tablets). — In 
the  combined  treatment  one-third  of  the  NaCl,  the  sodium  chloride  tablet 
(containing  twelve  grains),  and  one-sixth  to  two  alkaline  tablets  are  placed 
on  the  tongue  together  before  each  meal,  followed  by  eight  ounces  of  fluid 
(better  hot),  and  also  at  10  a.  m. ,  3  p.  m.  and  at  bedtime,  followed  by  eight 
ounces  of  fluid  (buttermilk  is  excellent),  i.  e. ,  every  two  hours,  and  followed 
by  a  glass  of  fluid.  The  six  eight-ounce  glasses  may  be  fluid  food — as  milk, 
buttermilk,  cream,  beef  tea,  egg-nog — fluid  nourishment.  This  visceral 
drainage  treatment  furnishes  alkaline  bases  (sodium,  potassium  and  ammon- 
ium) to  combine  with  the  free  uric  acid  in  the  urine,  producing  soluble  urates. 
Besides,  the  alkaline  laxative  tablet  increases  the  peristalsis,  sensation, 
absorption  and  secretion  of  the  intestinal  tract,  stimulating  the  sensation  of 
the  mucosa,  aiding  evacuation.  It  ends  in  correcting  the  pathologic  physiol- 
ogy of  the  tractus  vascularis.  The  object  of  the  visceral  drainage  treatment 
is  to  improve  elimination  and  digestion. 

I  have  termed  the  sodium  chloride  and  alkaline  laxative  method  the 
visceral  drainage  treatment.  The  alkaline  and  sodium  tablets  take  the  place  of 
the  so-called  mineral  waters.  I  continue  this  dietetic  treatment  of  fluids  and 
food  for  weeks,  months,  and  the  results  are  remarkably  successful,  especially  in 
pathologic  physiology  of  the  tractus  vascularis  and  adjacent  visceral  tracts. 
The  pulse  volume  becomes  full.  The  urine  becomes  clarified  like  spring- 
water  and  increased  in  quantity.  The  tractus  intestinalis  becomes  freely 
evacuated  regularly  daily.  The  blood  is  relieved  of  waste  laden  and  irritat- 
ing material.  The  tractus  cutis  eliminates  freely,  and  the  skin  becomes  normal. 
The  appetite  increases.  The  sleep  improves.  The  patient  becomes  hope- 
ful, natural  energy  returns.  The  sewers  of  the  body  are  drained  and  flushed 
to  a  maximum. 

The  maximum  function  of  viscera  by  means  of  fluid  diet,  activity,  induces 
maximum  drainage  of  viscera,  eliminating  irritating  matters  from  the  body 
and  insures  normal  peristalsis  and  normal  reflexes  for  the  vascular  tract. 

(c)  The  habitat  should  be  suitable.  It  should  allow  fresh  air  day  and 
night.     Environments  constitute  much  of  the  essence  of  living. 

(d)  The  avocation  should  suit  the  physique.  In  maximum  elimination — 
complete  visceral  drainage — every  visceral  tract  (urinary,  intestinal,  perspira- 
tory) must  normally  functionate.  Hence  all  rational  therapeutics  (fluid,  diet, 
habitat,  avocation)  must  be  applied  to  secure  maximum,  universal  visceral 
drainage.  No  single  visceral  tract  can  functionate  defectively  without  damage 
to  adjacent  tracts. 


PHYSIOLOGY  OF  TRACTUS   VASCULARIS  50«J 

( A)  PATHOLOGIC  PHYSIOLOGY  OF  THE   CONTENTS  OF  THE   TRACTUS    VASCULARIS.  — 

THE  BLOOD. 

The  pathologic  physiology  of  the  blood  cannot  be  separated  from  the 
pathologic  physiology  of  the  several  visceral  organs.  The  blood  represents 
universal  fluid  tissue  and  every  organ  receives  and  emits  material  to  it.  The 
blood  has  an  import  and  export  service  (transporting  oxygen  to  tissue  and 
carbonic  acid  gas  and  waste  products  from  tissue).  The  significant  blood — a 
medium  of  exchange  between  the  external  world  and  the  tissues— enters  every 
organ  through  the  tractus  vascularis,  distributing  nutritive  material  to  every 
tissue.  It  is  the  source  of  all  secretion.  When  one  concludes  the  enormous 
amount  of  interchange  (assimilation  and  waste)  between  the  blood  and  tissue, 
it  becomes  evident  that  the  pathologic  physiology  of  the  blood  is  a  wide  zone. 
It  also  becomes  evident  that  the  zone  of  pathologic  physiology  is  an  incipient 
zone  to  that  of  pathologic  anatomy.  First,  in  the  foreground  of  pathologic 
physiology  of  the  contents  of  the  tractus  vascularis  should  be  included  those 
diseases  which  indicate  dominant,  recognized  changes  in  the  blood,  as  anemia, 
chlorosis.  Second,  single  symptoms  may  represent  the  changes  of  an 
unknown  disease,  as  cachexia  ub  carcinoma,  diseases  of  the  adrenals. 

Here  projects  in  the  foreground  (primary)  hemogenous  disease  or  (secon- 
dary) visceral  disease.  The  composition  of  the  blood — plasma,  red  and  white 
corpuscles — depends  to  a  certain  extent  on  the  condition  of  the  tissue  in  the 
different  districts  of  the  body.  Though  the  blood  contains  an  extensive 
variety  of  substances,  its  composition  is  relatively  constant  on  account  of  the 
rapid  flow  of  its  current,  and  the  rapid  secretion  of  substances  occurring  in  it 
in  excess.  The  composition  of  the  blood  will  change  when  pathologic  physi- 
ology arises  in  any  organ.  The  essential  constituents  of  the  blood  with  which 
the  physician  deals  are:  (a)  red  corpuscles  (130,  to  1000  parts);  (b)  white 
corpuscles  (253,  to  1000  reds) ;  (c)  plasma  (800,  to  1000  parts  of  blood).  The 
great  typical  fields  of  pathologic  physiology  of  the  contents  of  the  tractus 
vascularis  are  1,  anemia— e.  g.,  chlorosis;  2,  leukemia— e.  g.,  splenic  and 
glandular  diseases;  3,  cachexia — e.  g.,  carcinoma  and  adrenal  diseases. 

Changes  in  the  blood  cells  and  hemaglobin  are  recognized  with  relative 
facility  and  hence  they  are  more  certainly  known  than  the  changes  in  the 
plasma.  The  contents  of  the  tractus  vascularis — the  blood — presents  a  rich 
field  for  study  in  pathologic  physiology  and  fortunately  for  prophylaxis.  The 
blood  has  an  extensive  range  of  pathologic  physiology  through  the  variation 
of  hemaglobin,  through  change  in  number  of  white  and  red  corpuscles,  through, 
changing  composition  of  plasma.  The  study  of  the  varying  stages  of  anemia 
(e.-  g.,  chlorosis)  and  hyperemia  (congestion)  present  far-reaching  possibilities 
in  therapeutics.     We  will  first  consider  the  red  corpuscles. 

/.     Red  Blood  Corpuscles  and  Hemaglobin  (1000  Reds  to  3  Whites). 

The  red  blood  corpuscles  constitute  about  \  of  the  blood  (130,  to  1000 
parts  of  blood).  The  most  striking  feature  of  pathologic  physiology  of  the 
blood  is  anemia.  In  anemia  the  marked  phenomenon  is  a  reduction  of  the 
hemaglobin  or  the  red  corpuscles  or  both.     Other  related  changes  doubtless 


510  THE  ABDOMINAL  AND  PELVIC  BRAIN 

occur  in  the  white  corpuscles  and  plasma.  Anemia  presents  many  forms, 
acute  and  chronic,  and  grades  (from  delicate  paleness  to  pernicious  anemia) 
as  well  as  numerous  conditions  of  etiology  (acute,  or  chronic  loss  of  blood). 
The  simplest  form  of  acute  anemia  results  from  sudden  loss  of  blood,  through 
vascular  wounds,  hemorrhages,  e.  g.,  during  parturition  excessive  quantities 
of  blood  may  be  lost  simply  producing  anemia.  The  grades  of  anemia 
depend  on  the  relative  quantity  of  blood  loss.  Should  the  hemorrhage 
exceed  a  certain  bound  the  patient  dies  from  suffocation;  there  are  insuffi- 
cient red  corpuscles  to  transport  oxygen  to  the  tissue  for  internal  respiration. 
Should  the  patient  lose  suddenly  15  per  cent  to  30  per  cent  of  corporeal 
blood,  it  may  require  weeks  and  months  to  recuperate,  during  which  time 
certain  phases  of  pathologic  physiology  of  the  tractus  vascularis  may  be 
observed.     The  patient  presents  a  pale  appearance. 

The  simplest  form  of  chronic  anemia  results  from  periodic,  repeated  or 
continuous  loss  of  blood,  as  menorrhagia  from  uterine  myoma,  repeated  loss 
of  blood  from  hemorrhoids,  from  renal  papillae.  The  blood  shows  a  dimin- 
ishing quantity  of  hemaglobin.  Chronic  and  acute  anemia  are  not  independ- 
ent diseases,  they  are  clinical  symptoms  of  pathologic  physiology.  In 
anemia  there  is  to  consider:  1,  the  quantity  of  oxygen  in  the  lung;  2,  the 
quantity  of  hemaglobin  in  the  blood ;  3,  the  rate  of  transportation  by  the 
blood  current;  4,  the  degree  of  interchange  of  the  oxygen  and  carbonic  acid 
gas  with  the  tissue.  Anemia  may  arise  not  only  from  hemorrhage  but  from 
insufficient  formation  of  red  blood  corpuscles.  The  red  blood  corpuscles 
forming  organs  are  acting  abnormally.  Starvation  as  a  rule  does  not  cause 
anemia.  If  the  hemaglobin  escape  from  the  red  blood  corpuscles  into  the 
plasma  the  condition  is  called  hemaglobinemia.  The  liver  forms  its  bile  pig- 
ments from  hemaglobin,  hence  in  hemaglobinemia  the  bile,  urine  and  feces 
will  become  richer  in  coloring  matter.  The  pathologic  physiology  of  hema- 
globin (albuminous  coloring  matter  of  blood)  includes  a  wide  zone.  It  is 
impossible  to  assert  the  minimum  quantity  of  hemaglobin  compatible  with 
life.  Anemia  may  progress  to  the  stage  of  air  hunger.  I  have  observed  several 
patients  recover  with  less  than  12  per  cent  of  hemaglobin.  Operations  are 
dangerous  with  hemaglobin  less  than  30  per  cent.  The  above  data  demon- 
strate that  the  normal  blood  stream  transports  more  oxygen  than  is  absolutely 
required  for  tissue  repair  and  waste.  Nature  employs  excessive,  abundant, 
supplies. 

The  blood  relates  itself  differently  in  the  various  form  of  chronic  and 
acute  anemia.  In  the  field  of  chronic  anemia,  chlorosis  is,  clinically,  a 
typically  well-characterized  anemic  disease  which  prevails  almost  exclusively 
in  females  between  the  ages  of  11  and  25  years — the  developmental 
period.  The  etiology  of  chlorosis  is  incompletely  known ;  it  is  a  kind  of  adoles- 
cent pathologic  physiology  of  the  blood — perhaps  a  sexual  phase,  like  a  vari- 
cocele, as  it  practically  recovers  spontaneously.  The  patient  presents  various 
transition  grades  of  color  from  normal  rosy  red  to  pale  green.  The  patient 
presents  a  plump  paniculus  adiposus — chlorosis  is  the  anemia  of  good  looking 
girls.     The  formation  of  the  blood  volume  may  be  normal,  the  plasma,  white 


PHYSIOLOGY  OF  TRACTUS  VASCULARIS  511 

and  red  corpuscles,  however,  altered  in  relations.  The  composition  of  the 
blood  may  be  changed.  There  may  be  diminished  red  corpuscles  and 
hemaglobin.  Acute  and  chronic  anemia  occupy  extensive  zone  of  pathologic 
physiology  allowing  time  for  prophylaxis. 

A  third  class  of  anemia  may  be  designated  pernicious  anemia,  a  disease 
in  which  the  red  blood  discs  may  finally  assume  the  highest  grade  of  changes 
in  dimension,  form  and  composition — ultimately  evident  pathologic  anatomy. 
However,  pernicious  anemia  has  a  considerable  range  of  pathologic  physiol- 
ogy. Anemia  renders  in  general  to  the  diminution  of  the  red  blood  disc  and 
hemaglobin — with  less  reference  to  the  white  blood  corpuscles  of  plasma. 

II.      White  Blood  Corpuscles  {Leucocytes). 

The  normal  relation  of  white  to  red  is  3  in  1000.  The  pathologic  anatomy 
relation  is  50  to  1000.  The  zone  of  pathologic  physiology  of  the  blood 
extends  through  a  range  of  4  to  40  whites  to  1000  reds.  In  other  words,  leu- 
cocytosis  is  1000  reds  to  4  whites.  From  these  data  the  leucocytes  of  the 
blood  are  labile  elements  markedly  influenced  by  conditions.  Leucocytosis 
is  pathologic  anatomy  where  there  are  50  whites  per  1000  reds.  In  leucocy- 
tosis there  exists  an  abnormal  number  of  white  blood  corpuscles.  There  are 
mononuclear  and  polynuclear  white  corpuscles.  The  origin  of  the  white 
corpuscle  is  not  definitely  settled  (spleen,  bone  marrow,  lymphoid  tissue). 
Leucocytes  is  supposed  by  some  to  be  the  rupture  of  hypoplastic  gland  tissue 
into  the  circulation.  This  accounts  for  the  various  kinds  of  cells  found  in  the 
blood.  On  account  of  the  variation  of  the  number  of  leucocytes  from  diff- 
erent normal  conditions  of  life — digestion,  gestation,  age,  sex — there  will  be 
physiologic  leucocytosis.  The  leucocytosis  of  pathologic  physiology  is 
of  special  interest  to  us,  though  its  signification  is  not  always  understood. 
For  example,  is  the  leucocytosis  of  infectious  disease  of  utility  to  the  patient? 
The  leucocytes  may  rise  to  30  whites  to  1000  reds.  Does  it  furnish  a  clue  for 
diagnostic  and  therapeutic  purposes?  Pathologic  physiology  as  regards  leu- 
cocytosis is  prevalent  in  middle  life.  Unfortunately  the  pathologic  physiol- 
ogy of  leucocytosis  frequently  merges  into  pathologic  anatomy  before 
diagnosis  has  been  established  and  when  treatment  becomes  of  little  avail  in 
an  advanced  terminal  disease.  With  established  pathologic  anatomy  in  leu- 
cocytosis (especially  and  splenic  hypertrophy)  the  termination  of  the  disease 
is  generally  fatal  in  a  couple  of  years.  The  hope  of  treatment  benefiting  a 
leucocytotic  is  while  the  disease  is  in  the  plane  of  pathologic  physiology. 

Leucocytosis  was  first  observed  by  Xavier  Bichat  (1771-1802)  in  1800. 
Velpeau  observed  the  hypertrophy  of  the  spleen  in  relation  to  leucocytosis. 
Donne  (  )  in  1844  thought  that  leucocytosis  was  due  to  imperfect  transfor- 
mation of  white  into  red  corpuscles.  In  1845  Dr.  Hughes  Bennett  and  Dr. 
Craigie  each  published  a  case.  To  Dr.  Hughes  Bennett  is  due  the  credit  of 
recognizing  the  salient  features  of  leucocytosis  and  he  proposed  the  term  leu- 
cocythemia.  In  1845  Rudolph  Virchow  published,  originally  and  independ- 
ently, excellent  details  and  comprehensive  views  of  a  case.  To  this  date  the 
changes  in  the  blood  had  been  recognized  only  after  death.     The  changes  of 


512  THE  ABDOMINAL  AND  PELVIC  BRAIN 

the  blood  during  life  in  leucocytosis  was  first  observed  by  Dr.  H.W.  Fuller. 
The  first  case  of  leucocytosis  diagnosed  during  life  in  Germany  was  by  Dr. 
Vogel  in  1848.  At  present  writing  no  known  remedy  is  capable  of  checking 
the  fatal  course  of  leucocytosis. 

Cachexia  presenting  a  peculiar  white,  waxy  color  of  the  skin,  depends 
on  the  deteriorating  effect  of  the  disease  on  individual  organs  as  from  malig- 
nancy, tuberculosis,  arsenic,  malaria,  alcohol,  goiter,  etc.  Cachexia  is  associ- 
ated with  a  condition  of  chronic  ill  health  depending  on  depraved  state  of 
blood,  from  loss  of  blood  elements,  malnutrition  or  the  presence  of  morbific 
elements  (uremia,  defective  elimination).  Pathologic  physiology  plays  a 
considerable  role  in  the  pre-cachectic  stage,  previous  to  the  establishment  of 
recognizable  pathologic  anatomy.  The  term  cachexia  and  constitutional  dis- 
ease are  with  some  synonymous. 

III.      Plasma  {Liquor  Sanguinis). 

Blood  plasma  is  composed  of  blood  serum  and  fibrin.  Fibrin  constitutes 
about  |  of  1  per  cent  of  blood.  If  blood  contains  1  per  cent  of  fibrin  it  has 
merged  into  pathologic  anatomy,  which  is  especially  observed  in  inflammatory 
states.  The  range  of  pathologic  physiology  as  regards  fibrin  is  from  \  of  1 
per  cent  to  |  of  1  per  cent  in  the  ascending  scale.  In  the  descending  scale 
it  may  be  less  than  tV  of  1  per  cent,  as  in  the  anemias  and  septicaemias. 
The  knowledge  of  pathologic  physiology  of  blood  coagulation  is  defective, 
hence  our  knowledge  of  the  pathologic  physiology  of  blood  coagulation  is 
likewise  defective.  The  plasma  of  the  blood  is  of  significance  on  account  of 
the  contained  fibrin  which  is  the  base  of  thrombosis  and  ultimate  embolism. 
The  blood  serum  is  able  to  destroy  varieties  of  foreign  cells  and  bacteria. 
The  blood  plasma  contains  numerous  ferments,  which  act  as  an  enzyme, 
alexin  or  complement.  Some  suppose  that  the  leucocytes  produce  the 
alexins.  The  signification  of  the  blood  plasma  may  be  noted  in  the  ideal 
administration  of  certain  so-called  anti-toxins  to  cure  disease,  as,  diphtheria, 
tetanus.  If  foreign  cells,  as  bacteria,  be  injected  into  an  animal  the  blood 
serum  of  the  animal  acquires  the  property  of  causing  the  cells  to  agglutinate. 
The  blood  serum  contains  a  variety  of  substances  with  a  variety  of  function. 
It  is  well  for  the  practitioner  to  remember  for  practical  purposes,  that  the 
chief  salts  of  the  serum  are  sodium  chloride  (NaCl),  sodium  carbonate 
(NaHC03)  with  phosphates  and  alkalies.  If  the  blood  plasma  becomes 
diluted,  attenuated,  it  is  said  to  be  in  a  state  of  hydraemia,  as  in  kidney  and 
heart  disease.  The  blood  may  become  thick,  excessively  condensed,  as  in 
Asiatic  Cholera  or  in  extensive  watery  diarrhea. 

Treatment  of  Pathologic  Physiology  of  the  Blood. 

The  treatment  of  pathologic  physiology  of  the  blood  demands  a  knowl- 
edge of  etiology.  When  the  red  corpuscle,  white  corpuscle  or  plasma 
manifests  abnormal  function  (pathologic  physiology),  first  and  foremost  must 
we  begin  the  search  for  the  diagnosis  with  vigor,  as  the  diagnostic  data  are 
still  few  and  somewhat  uncertain.     If  it  be  anemia  from  loss  of  blood  (uterine 


PHYSIOLOGY  OF   TRACTUS  VASCULARIS  513 

sarcoma,  myoma,  hemorrhoids,  the  condition  may  be  palliated  or  cured.  If 
it  be  anemia  from  chlorosis,  a  sexual  phase,  the  health  can  be  improved  by 
treatment,  and  also  it  is  a  self  limited  disease  (15  to  24  years).  The  associated 
conditions  of  glandular  hypertrophy  may  aid  as  a  general  hyperplasia,  splenic 
or  hepatic  hypertrophy.  The  pathologic  physiology  of  the  blood  should  allot 
the  physician  ample  time  to  diagnose  and  institute  appropriate  treatment 
before  the  destructive  fatal  pathologic  anatomy  dominates  the  field.  When 
the  fatalistic  cachexia  presents  its  specter,  pathologic  physiology  of  the  blood 
has  generally  merged  into  hopeless  pathologic  anatomy. 

PATHOLOGIC  ANATOMY. 

The  detection  of  the  terminal  disease  (pathologic  anatomy)  from  the 
pathologic  physiology  of  the  blood  requires  the  best  heads  and  the  finest  of 
skill.  If  the  terminal  carcinoma  could  be  detected  in  the  stage  of  pathologic 
physiology,  i.  e.,  in  the  precarcinomatous  stage,  it  could  be  practically  cured, 
as  it  is  in  the  incipient  stage— a  local  disease.  The  diagnosis  of  the  pathologic 
physiology  of  the  blood  cannot  be  separated  from  the  pathologic  physiology 
of  individual  viscera.  For  example,  carcinoma  of  any  viscus  produces  patho- 
logic physiology  of  the  blood  (cachexia).  Again,  pathologic  physiology  of 
the  blood  may  arise  with  no  palpable  course  until  hypertrophy  of  the  glands, 
spleen,  or  liver  appears. 

Leukemia,  a  disease  of  middle  life,  though  in  the  incipient  stage  is  that 
of  pathologic  physiology,  yet  leads  later  to  pathologic  anatomy  and  generally 
to  a  fatal  issue,  however,  through  a  chronic  course.  Leukemic  changes  arise 
through  rupture  of  the  hyperplastic  tissue  in  the  vascular  tract.  This 
explains  the  variety  of  cells  found  in  the  blood.  The  etiology  of  leukemia  is 
unknown.  Some  consider  it  an  infectious  disease.  Leukemia  was,  originally, 
chiefly  referred  to  the  spleen  but  other  sources,  as  the  bone  marrow,  account 
for  a  share.  The  various  forms  of  leucocytosis  may  exist  as  long  as  patho- 
logic physiology  endures — ultimately  pathologic  anatomy  appears.  Whether 
the  origin  of  the  leucocytes  be  the  spleen  or  glands  one  cannot  decide  until 
physical  symptoms  arise.  The  study  of  pathologic  physiology  of  the  blood 
will  progress  when  physicians  practically  examine  all  patients,  and  the  subject 
of  hematology  is  constantly  taught  as  a  required  curriculum  in  the  colleges. 
It  is  by  cultivation  of  the  study  of  pathologic  physiology  of  the  blood  that 
we  may  hope  for  early  diagnosis  of  impending  disease,  the  application  of 
effective  remedies  as  well  as  rational  prophylaxis.  When  pathologic  physi- 
ology of  the  blood  can  only  be  discovered,  the  aim  of  the  clinician  must  be 
to  correct  the  abnormal  deviation,  the  abnormal  function,  of  plasma,  red  or 
white  corpuscle.  These  consist  in  the  application  of  therapeutics,  as  diet 
(food  and  fluid),  induction  of  maximum  visceral  function  (visceral  drainage), 
recognized  remedies,  (habitat,  avocation),  prophylaxis. 


33 


CHAPTER   XXXVIII. 

THE    PATHOLOGIC   PHYSIOLOGY  OF  (I.)  TRACTUS  LYMPHATI- 

CUS,  (II.)  LYMPH. 

An  original  and  enterprising  man  is  opposed — opposition  develops  strength,  and 
criticism  accuracy. 

A  fever  in  your  blood!     Why,  then,  incision  would  let  her  out  in  saucers. — 
Shakespeare,  in  Love's  Labor  Lost. 

I.   TRACTUS  LYMPHATICUS. 

The  tractus  lymphaticus  begins  and  ends  in  the  veins.  It  is  a  venous 
appendage.  It  was  a  late  developmental  addition,  differentiation  of  the 
blood  vascular  system — an  additional  circulatory  apparatus. 

The  tractus  lymphaticus  resembles  the  tractus  venosus,  (a)  in  possessing 
afferent  or  converging  vessels  which  course  from  periphery  to  center;  (b)  in 
being  divided  into  two  sets — superficial  and  deep',  (c)  in  contour,  the 
possession  of  valves — constrictions  and  dilatations. 

The  tractus  lymphaticus  differs  from  the  tractus  venosus,  (d)  in 
traversing  glands;  (e)  in  its  reverse  arrangement — i.  e.,  the  lymphatic  vessel 
does  not  increase  in  dimension  from  periphery  to  center  like  the  vein;  (f)  the 
progressive  movements  of  the  lymph  depend  exclusively  on  the  parietes  of 
the  lymphatic  vessel — that  of  the  venous  blood  chiefly  on  the  cardiac  action ; 
(g)  the  lymphatics  communicate  with  intercellular  spaces  and  serous  sacs. 

The  tractus  lymphaticus  consists  of:  (A),  {VASA  LYMPHATIC  A), 
Peripheral  Anastomosing  Plexuses  of  Lymph  Vessels,  which  originate  in  the 
meshes  of  the  connective  tissue.  These  lymph  channels,  converging  and 
uniting,  pass  to  the  lymph  glands,  or  nodes.  In  the  pathologic  physiology 
of  the  lymph  vessels  redness  (hyperaemia)  along  the  line  of  vessels  and 
oedema  are  conspicuous  features. 

Vasa  lymphatic  or  lymph  vessels  arising  from  all  parts  of  the  body  were 
discovered  almost  simultaneously  by  George  Joylife  (1637-1658),  an  English 
physician,  in  1652;  Olaf  Rudbeck  (1630-1702),  a  Swede  of  Upsala  in  1651; 
Thomas  Bartholin  (1616-1680),  a  Danish  anatomist  of  Copenhagen  from  1650 
to  1667.  Bartholin  proposed  the  name  vasa  lymphatica.  The  chief  location 
of  lymphatic  vessels  is  the  connective  tissue  especially  associated  with  blood 
vessels.  The  valves  of  lymphatic  vessels  are  absent  at  their  origin  and  in  the 
capillaries.  The  valves  are  paired  and  numerous  but  irregularly  located  in 
the  collecting  vessels,  however,  rare  in  the  final  collecting  trunks — thoracic 
ducts.  The  arrangement  of  the  vasa  lymphatica  consist  of:  (a)  superficial 
or  epifascial  set  and  (b)  deep  or  subfascial  set — communicating  with  each 
other.  The  general  organs  or  regions  of  the  body  are  drained  by  converging, 
collecting  lymphatic  vessels — intermediate  collecting  trunks.  The  lymph 
capillaries  consist  of  valveless  endothelial  tubes.  The  common  collecting 
trunks  consist  of  three  coats,  viz.,  (a)  the  internal  endothelial  layer;  (b)  the 
middle  muscular  layer;  (c)  the  external  connective  tissue  layer. 

514 


TRACTUS    LYUrHATlCUS   AND    LYMPH 


515 


Chyle    Vessels   (Lac  fen  Is). 

Vasa  chylifera  or  the  lacteals  were  first  observed  in  the  mesentery  of  man 
by  Herophilus  (310  B.  C. ),  a  Greek  physician  living  in  Egypt,  while  he  was 
dissecting  living  criminals. 

Erasistratus  (34O-280  B.  C),  a  Greek 
physician,  observed  the  chyle  vessels  or 
lacteals  while  dissecting  kids  but  named 
them  arteries.  However,  Gasparo  Aselli 
(1581-1626)  professor  of  anatomy  and 
surgery  at  Pavia,  Italy,  a  prince  among 
anatomists,  discovered  the  lacteals  while 
performing  vivisection  in  a  dog.  July  23, 
1622,  Aselli 's  work  (lacteals)  was  pub- 
lished posthumous  by  his  friends. 

(B),  (GLANDULE  LYMPH AT- 
LCAi),  Lymph  Glands  or  Nodes,  which 
are  structures  that  receive  (afferent  ves- 
sels) and  emit  (efferent  vessels)  lymph 
vessels.  The  glands  produce  leucocytes 
and  modify  traversing  material.  It  is 
estimated  that  man  has  some  500  lymph 
glands  or  nodes  and  that  the  lymph 
traverses  one  or  more  glands  before  ter- 
minating in  (subclavian)  veins.  Glands 
alter  lymph  owing  to  slow  circulation. 
The  glands  modify  the  traversing  inert  or 
living  particles  and  imprison  them,  as  the 
carbon  infiltration  glands  of  the  bronchia. 
In  pathologic  physiology  of  the  tractus 
lymphaticus  hypertrophy  or  tenderness 
of  the  glands  is  a  conspicuous  character- 
istic. 

(C),  (TRUNCL  LYMPHATLCL), 
Lymph  Trunks,  are  large  lymph  vessels 
which  conduct  or  transport  the  lymph 
from  the  lymph  glands  or  nodes  to  the 
(subclavian)  veins.  The  chief  ones  are 
the  left  and  right  thoracic  ducts. 

The  lymph  trunks  are  the  thoracic 
duct  (left)  and  the  thoracic  duct  (right). 
Formerly  it  was  thought  the  wounds  of 
the  thoracic  duct  were  fatal,  however, 
recent  observation  (H.  Cushing,  P.  Allen, 
and  others)  demonstrates  that  the  thor- 
acic duct  wounds  are  frequently  not  fatal,  recovery  resulting  from:  (a) 
spontaneous   closure  (coagulation   contraction   of   the   duct  wall) ;    (b)  free 


•  and  richt  lymphatic  ducts. 


DUCTUS 


THORACICUS 
ET    SINISTER 


DEXTER 


Fig.  140.  The  left  thoracic  duct  with 
the  chief  (a)  isthmus  constriction  in  its 
central  portion,  the  dilated  (b)  cisterna 
lymphatica  at  its  distal  end  and  the  (c) 
cervical  dilatation  at  its  proximal  end 
(which  terminates  in  the  vena  subclavia 
sinistra),  the  right  thoracic  duct  term- 
inating in  the  vena  subclavia  dextra.  Is 
the  caliber  of  the  thoracic  duct  (left) 
sufficient  to  transport  f  of  the  lymph  of 
the  organism?  (Gray). 


51G 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


collateral  circulation;  (c)  ligation  (suture)  of  the  wound.  If  the  duct 
leaks  lymph  it  should  be  ligated  proximal  and  distal  to  the  perforation, 
allowing  resumption  by  collateral  circulation.  (The  lymphatic  system 
includes  the  terms  canalicular  system,  perivascular  lymph  spaces,  lymph  cap- 
illaries, chiliferous  vessels — pleural,  peritoneal,  pericardial  and  synovial 
(serous)  cavities,  stomata,  lacteals.) 

The  number  of  lymph  channels  and  glands  are  unequally  or  non-uni- 
formly  distributed  in  the  organ- 
ism, occurring  most  frequently  in 
vascular  parts.  The  number  and 
caliber  depend  on  the  density  of 
tissue.  Lymph  channels  (closed, 
e.  g.,  peritoneum,  pleura),  in  gen- 
eral are  lined  by  endothelium  in 
contradistinction  to  (unclosed) 
channels,  (e.  g.,  digestive  and 
genital  tracts),  which  are  lined  by 
epithelium.  The  valves  of  lymph 
channels  are  folds  of  endothelium. 
The  tractus  lymphaticus  possesses 
more  variation  than  any  other 
visceral  tract.  The  form  of  the 
whole  branching  lymphatic  vas- 
cular system  is  that  of  a  cone. 
The  cone  base  or  periphery  is  the 
vast  connective  tissue  spaces  of 
the  whole  body.  The  cone  apex 
or  center  is  the  termination  of  the 
lymphatic  trunk  (thoracic  ducts) 
in  the  veins  (subclavian). 
Lymphatic  vessels  arise  from 
intercellular  spaces,  however, 
especially  from  immediately  be- 
neath free  surfaces  as  skin  serosa, 
mucosa.  The  lymphatic  vessels 
are  solidly  and  compactly  anas- 
tomosed. Hence  the  lymph 
plasma  may  flow  in  all  directions 
(like  the  blood  in  the  utero- 
ovarian  artery)  direct  or  reverse  to  insure  complete  cell  nourishment  under 
complicated  conditions.  The  object  of  the  tractus  lymphaticus  is  universal 
cell  nourishment  and  universal  cell  drainage.  The  functions  of  the  tractus 
lymphaticus  (sensation,  peristalsis,  absorption,  secretion)  is  controlled  by  the 
nervus  vasomotorius  (sympathetic).  The  tractus  lymphaticus  is  richly  sup- 
plied by  a  plexiform,  nodular  network,  a  fenestrated  anastomosed  meshwork 
of  the  nervus  vasomotorius  which  controls  its  physiology.     The  lymphatic 


Fig.  141. *-The  lymphatics  of  the  head  und  neck. 

LYMPHATICS  OF   HEAD  AND 


(Sappey.) 

NECK 


Fig.  141.  This  figure  presents  the  source  (vasa 
lymphatica),  glands  (glandular  lymphatics)  and 
termination  of  the  right  thoracic  duct  (in  the  right 
subclavian  vein).  The  direction  of  the  lymph  chan- 
nels demonstrated  why  the  lymph  glands  in  the 
neck  enlarge  toward  the  clavicle.     (Sappey.) 


TRACTUS   LYMPHATICUS   AND   LYMPH 


517 


vessels  accompany  the  veins.  The  lymphatic  vessels  ensheath  the  veins  as  a 
plexiform  anastomosing  net  or  fenestrated  meshwork — resembling  the  plexi- 
form,  nodular  net  or  fenestrated  anastomosing  meshwork  of  the  nervus 
vasomotorius  ensheathing  the  arteries,  i.  e.,  the  nervus  vasomotorius  ensheath 
the  arteries  as  the  tractus  lymphaticus  ensheath  the  veins. 

Thoracic  Duct  (Unpaired). 

Ductus  thoracicus  sinistra,  ductus  pecquetianus,  was  discovered  by  Jean 
Pecquet  (of  Paris,  France,  1622-1674)  in  1(349,  in  a  dog.  It  was  discovered  by 
Olaus  Rudbeck  (of  Upsala, 
Sweden,  1630-1702)  in  man, 
in  1650. 

Also  Thomas  Bartholin 
(1616-1680)  is  credited  with 
discovery  of  the  thoracic 
duct  in  man.  John  Wesling 
in  1634  saw  the  thoracic 
duct.  The  thoracic  duct  is 
in  general  \  of  an  inch  in 
diameter  and  18  inches  in 
length  with  non-uniform  cal- 
iber and  sinuous  course  with 
minimum  caliber  at  its  mid- 
dle portion.  It  is  especially 
dilated  at  the  distal  end  (re- 
ceptaculum  lymphatica)  and 
at  the  proximal  end  is  an 
elongated  ampulla  (which  I 
shall  term  its  cervical  dila- 
tatioii). 

The  thoracic  duct  may 
bifurcate,  forming  two  or 
several  branches,  a  network, 
and  reunite  in  its  course. 
Its  valves  are  the  most  lim- 
ited in  number  and  dimen- 
sions of  any  portion  of  the 
tractus  lymphaticus.  Its  two 
most  remarkable  valves  are  located  at  its  ("cervical  dilatation")  termination  in 
the  subclavian  vein  where  the  free  borders  of  the  valves  are  directed  toward 
the  venous  lumen  in  order  to  oppose  influx  of  venous  blood  into  the  thoracic 
duct.  The  two  ductus  thoracici — ductus  thoracicus  major  (sinister)  et  minor 
(dexter) — flow  in  the  direction  of  least  resistence,  i.  e.,  they  flow  into  the  sub- 
clavian veins  at  the  most  distant  point  from  the  intra-thoracic  and  intra- 
abdominal pressure.  Has  a  duct  of  two  lines  or  £  of  an  inch  in  diameter 
ample  lumen  to  allow  %  of  the  lymphatic  fluid  (constituting  about  \  of  the 
bcdy  weight)  to  traverse  it? 


LYMPHATICUS   ENSHEATHING  A  VEIN 

Fig.  142.  The  lymphatic  vessels  ensheathing  the  por- 
tal vein  as  a  plexiform,  anastomosing  nodular  (valves) 
fenestrated  meshwork.  The  tabular  lymph  apparatus 
richly  ensheathing  the  vein  transports  abundant  fluid 
for  nourishment.     (Teichman.) 


518 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


Ductus  TJwracicus  dextra  is  located  at  the  right  side  and  base  of  the  neck. 
Its  dimensions  are:  length  an  inch,  diameter  1-8  of  an  inch.  It  terminates 
in  right  subclavian  vein.  It  is  the  common  collecting  lymph  trunk  for  the 
right  side  of  the  head  and  neck,  right  proximal  extremity,  right  lung,  right 
heart.  The  thoracic  duct  is  nonuniform 
in  caliber,  possessing  dilatations  (reser- 
voirs) and  constrictions  (isthmuses). 

(1)      Receptaculum    Lymphatica    {Distal 
Dilatation). 

Receptaculum  chyli,  cisterna  chili, 
cisterna  lymphatica  or  chyle  reser- 
voir was  discovered  [by  Jean  Pecquet 
(1622-1674)  of  Paris,  France,  in  1649. 
The  cisterna  lymphatica  was  independ* 
ently  discovered  by  Olaf  Rudbeck  (1630- 
1702),  president  of  the  University  of 
Upsala,  Sweden.  In  general  the  dimen- 
sions of  the  receptaculum  lymphatica  is 
\  of  an  inch  in  diameter  and  2l/>  inches 
in  length.  It  is  an  oblong  formed  sac  or 
dilatation  at  the  distal  end  of  the  thoracic 
duct,  located  opposite  to  the  I  and  II 
lumbar  vertebrae. 

(2)     Cisterna    Lymphatica    Cervicis 
{Proximal  Dilatation). 

The  thoracic  duct  in  the  region  of  the 
neck  possesses  a  dilatation  which  may  be 
termed  the  "cervical  dilatation"  or  cis- 
terna lymphatica  cervicis.  It  is  a  spindle 
or  oblong  formed  swelling  of  the  duct 
located  at  its  terminal  end.  It,  as  well  as 
other  dilations,  has  been  termed  an  am- 
pulla. 

(3)  Isthmus    Medius    {Middle   Isthmus). 


A  LYMPHATIC  GLAND  WITH  ITS 

AFFERENT  AND  EFFERENT 

VESSELS 

Fig.  143.  The  valved  afferent  vessels 
are  more  numerous  than  the  valved  effer- 
ent (Testut). 


The  thoracic  duct    possesses  a  min- 
imum caliber  at  its  medial  portion,  hence 

I  shall  term  this  the  middle  isthmus.     It  is  the  chief  constriction  or  isthmus 
of  the  thoracic  duct. 

II.       THE  LYMPH  (LYMPH  PLASMA). 

The  contents  of  the  tractus  lymphaticus  consists  of:  (A)  the  lymph  or 
lymph  plasma — a  fluid  tissue;   (B)  the  leucocyte — a  guest  of  lymph  plasma. 


TRACTUS    LYMPHATICUS    AND    LYMl'H 


519 


(A).      Lymph — Lymph  Plasma. 

Lymph  plasma  originates  from  blood  plasma.  The  lymph  or  lymph 
plasma  originates  as  a  capillary  infiltration  from  the  blood  serum.  Lymph 
is  doubtless  also  a  product  of  cell  secretion.  In  composition  lymph  plasma 
appears  to  be  a  mechanical  and  secretive  product  from  the  blood.  Perhaps 
lymph  should  be  viewed  chiefly  as  a  secretion  of  the  endothelial  (blood  cap- 
illary) cell.  Lymph  is  different  from  blood — it  is  more  acid  (is  less  in 
glucose),  as  urine  is  more  acid  than  blood.  Lymph  plasma  is  fluid  that  has 
escaped  from  the  blood  plasma  in  the  capillaries  and  its  composition  varies 
according  to  source  and  organ  activity.  It  is  a  peculiarity  that  though  the 
lymph  should  be  viewed  chiefly  as  the  product  of  cell  secretion,  instead  of 
being  eliminated  externally,   it  is  returned  to   the  venous  blood,  to  retravel 


LYMPH  VESSELS  OF  THE  TRACHEAL  MUCOSA 

Fig.  144  Observe  anastomosing  superficial  and  deep  lymphatics  as  well  as  valves.  The 
number  and  caliber  of  the  lymph  channels  demonstrate  its  functional  transporting  capacity. 
(Teichman.) 

the  arteries.  However,  the  lymph  is  modified  by  the  lymph  glands  and  pul- 
monary endothelium  (oxygen).  It  is  a  process  which  resembles  the  elabora- 
tion of  the  ductless  glands  (spleen,  thyroid,  ovary,  thymus,  adrenal). 

Physically  the  lymph  is  in  general  an  odorless,  colorless,  viscid  fluid. 
Digestion  produces  a  milky  color  in  lymph  plasma.  The  quantity  of  lymph 
is  estimated  from  \  to  \  the  weight  of  the  body.  The  quantity  varies 
extensively  according  to  corporeal  activity.  Its  specific  gravity  is  1.017. 
Practically  the  lymph  is  a  transparent  alkaline  fluid,  perchance,  of  reddish 
yellow  color.  It  is  soluble  in  water,  becoming  turpid  in  alcohol  Lymph 
coagulates  with  more  facility  than  blood  and  becomes  a  scarlet  red  in  contact 
with  oxygen  and  purple  red  in  contact  with  carbonic  acid.  The  lymph  plasma 
performs  an  export  and  an  import  service.  It  conducts  nourishment  (fluid) 
to  the  cell  and  floats  waste  material  (fluid)  from  the  cell.     It  performs  its 


520 


THE  ABDOM1XAE  AND  PELVIC  BRAIX 


labor  through  a  fluid  medium,  saturating  the  cell  (nourishment)  and  irrigating 
the  cell  (drainage).  Lymph  plasma  coagulation  renders  less  fibrin  than  that 
of  blood  plasma.  This  is  significant,  for  fibrin  is  liable  to  obstruct  vessels 
and  produce  thrombosis — eventually  embolism.  The  chief  chemical  constit- 
uents of  lymph  consists  of  albuminoids  (less  than  that  of  blood)  fats,  various 
metalic  salts  (NaCl  phosphates,   sulphates,  alkaline  carbonates). 

(B).     Leucocyte — White  Blood  Corpuscle. 

The  origin  of  the  leucocyte  is:  (a)  medulla  (bone  marrow);  (b)  mesob- 
last  (blood  vascular  endothelium);  (c)  connective  tissue;  (d)  lymph  glands 
or  nodes. 

The  location  of  the  .  l/liVi/  <MJM§&$£Ni(&S$^ 
leucocyte  is  in  order  of 
frequency:  (a)  in  the 
lymph  plasma;  (b)  in  the 
blood  plasma;  (c)  in  the 
connective  tissue. 

The  structure  of  a  leu- 
cocyte consists  of  a  nu- 
cleus and  a  surrounding 
protoplasm. 

The  number  of  leu- 
cocytes in  man  to  the 
cubic  millimeter  are  about 
8,000  (Ranvier).  The 
number  of  leucocytes  are 
increased  after  passing 
through  glands.  The 
number  of  leucocytes  is 
greater  in  the  center  than 
in  the  periphery  of  the 
body  organism. 

The  neucleus  of  the 
leucocyte  varies  in  num- 
ber, dimension,  form, 
location.  The  nucleus  is 
surrounded  by  proto- 
plasm, an  almost  imper- 
ceptible zone  of  non- 
homogenous       matter. 

The  polymorphism  of  the  leucocyte  nucleus  has  vigorously  engaged  numerous 
cytologists  with  consequent  multiple  views  as  to  its  cause. 

The  protoplasm  varies  in  form,  dimension,  structure.  The  contents  of 
the  protoplasm  varies  from  environments  as  iron  granules,  redblood  corpus- 
cles, debris,  microbes  or  their  products,  particles  of  air  and  so  forth. 

Physically  the  leucocyte  is  practically  a  colorless,  soft,  extensible  non- 


INGUINAL  GLANDS  OF  LYMPHATICS 

Fig.  145.  This  figure  represents  the  course  of  the  lympha- 
tics from  the  genitals  and  rectum  to  the  abundant  inguinal 
glands — barriers  of  infection  which  imprison,  sterilize  or 
digest  (destroy)  infectious  or  inert  material.  The  inguinal 
glands  are  affected  by  carcinoma  and  infectious  material 
from  genitals  and  rectum.     (Sappey.) 


TRACTUS  LYMPHATICUS   AND   LYMPH  521 

homogenous  mass  of  protoplasm,  noncapsulated  (without  covering).      It  is 
viscous  and  adheres  to  the  most  smooth  surface.       Thus  when  circulation 

slows  it  lodges  against  vessel  wall. 

to  a  a 


LYMPHATICS  OF  THE  INTERNAL  GENITALS 


Fig  146  This  illustration  of  the  lymphatics  after  Dr.  Wm.  Nagel  and  Porier  demonstrates 
that  the  lymphatics  accompany  the  vessels-in  this  figure  they  follow  the  utero-ovarian 
vascular  circle  (circle  of  Byron  Robinson).  The  lymphatics  of  the  genitals  are  of  practical 
importance  on  account  of  the  frequent  location  of  carcinoma  in  the  genitals  and  their  dis- 
tribution of  the  carcinoma  through  the  lymphatics. 

The  chief  chemical  constituents  of  a  leucocyte  are,  albuminoids,  nuclein, 
insoluble  matter,  fat  cholestrin.     These  substances  are  important  in  meta- 
bolism, e.  g.,  the  nuclein  will  produce  uric  acid. 


522 


THE  ABDOMINAL   AXD   PELVIC  BRAIN 


Biologically  the  leucocyte  or  white  corpuscle  possesses  the  primary  prop- 
erties of  living  matter,  viz. :  sensibility,  mobility  (rhythm),  peristalsis, 
absorption,  secretion,  reproduction.  One  of  the  most  significant  characteris- 
tics of  the  leucocyte  is  that  of  viability  endowing  it  with  the  quality  of  a  pro- 


LYMPH    CHANNELS    AND    GLANDS    DRAINING    THE    TRACTUS    GENITALIS 

(SAVAGE) 

Fig.  147.  The  tractus  genitalis  is  abundantly  supplied  by  lymphatics  and  consequently 
possesses  a  rich  lymphatic  drainage.  The  tractus  genitalis  is  peculiarly  liable  to  be  attacked 
by  bacterial  infection  and  carcinoma — both  manifest  in  the  annexed  tractus  lymphaticus. 
Infectious  or  carcinomatous  material,  on  account  of  the  luxuriant  anastomoses  of  the  genital 
lymph  channels  may  appear  to  avoid  certain  of  the  adjacent  genital  glands  and  to  attack 
glands  more  distant  from  the  genitals.  In  other  words  the  infectious  or  carcinomatous 
material  may  not  attack  the  genital  lymphatic  glands  in  the  direct  order  of  the  course  of 
their  arrangements.  This  illustration  demonstrates  the  futility  of  attempting  to  extirpate 
all  the  lymphatic  glands  attending  a  carcinomatous  infected  genital  tract — microscopically 
one  is  incapable  of  deciding  whether  a  lymph  gland  be  hypertrophied  from  bacterial  infec- 
tion or  carcinomatous  infection. 


tector,  a  body  guard — a  mobile  sentinel.  It  is  a  migratory  cell  (the  wandering 
cell  of  Recklinghausen).  It  is  a  mobile  tissue  inspector,  a  heraldic  warner 
for  bodily  protection.  The  leucocyte  is  a  guardian  against  foreign  invaders. 
it  is  a  tester  of  ingesta,  it  is  a  filtering  barrier,  a  retention  prison. 


TRACTUS   LYMPHATICUS   AND    LYMPH 


523 


The  leucocyte  absorbs,  imprisons,  sterilizes  matter.  It  digests  some 
material  (food,  bacteria),  it  imprisons  some  (indigestible,  coloring  matter), 
it  sterilizes  some  (bacteria,  ferments).  These  properties  enable  the  leucocyte 
to  protect  or  supervise  against  excessive  invasion  of  bacteria,  poisonous 
matter,  ferments. 

The  leucocyte  reproduces  itself  by  amitosis  (direct  division)  and  karyo- 
kinesis  (indirect  division).  The  leucocyte  is  a  primordial  factor  of  life  and 
its  perpetuation. 

The  leucocyte  is  a  vital,  primordial,  protoplasmic  element  which  retains 
its  primary  property  of  free  and  independent  life — sensation,  motion,  absorp- 
tion, secretion,  reproduction — adopting  itself  to  differentiation,  environ- 
ment.    It  is  a  functionator  preceding  a  constructor. 

The  vital  resistance  or  constitutional  power  of  a  leucocyte  is  remarkable 
against  destructive  agen- 
cies. Yerworn  demon- 
strated that  24  hours  after 
bodily  death  of  the  organ- 
ism the  majority  of  the 
leucocytes  are  living. 
They  may  retain  their 
properties  external  to  the 
general  organism  for  3 
weeks  (Recklinhausen, 
Ranvier). 

The  chief  classifica- 
tion of  different  leucocytes 
are :  (a)  microcytes ;  (b) 
macrocyscs ;  (c)  cells  with 
neutrophile  granules;  (d) 
cells  with  acidophile 
granules;  (e)  cells  with 
metachromatic  basophile 
granules.  This  classifica- 
tion demonstrates  the  extensive  range  of  physiology  (and  consequent  exten- 
sive field  of  pathologic  physiology)  included  within  the  range  of  the  leucocytes. 
As  disease  is  deviating  or  abnormal  physiology  the  key  to  its  etiology, 
therapuesis  and  prophylaxis  accurate  knowledge  of  organ  functions.  The 
functions  of  the  tractus  lymphaticus  are:  I,  sensation;  II,  peristalsis;  III, 
absorption;  IV,  secretion.  Disease  in  the  lymphatic  tract  consists  in  devia- 
tion, abnormal  repetition,  of  one  or  all  the  above  four  functions.  The  four  func- 
tions manifesting  pathologic  physiology  in  the  disease  of  the  tractus  lympha- 
ticus will  be  recognized  by  being  excessive,  deficient,  disproportionate. 

I.      SENSATION  (EXCESSIVE,     DEFICIENT,  DISPROPORTIONATE). 

1.  Excessive  sensation  in  the  tractus  lymphaticus  may  be  associated  with 
irritability  of  the  peripheral  nerve  ending  in  the  endothelium.  Also  the 
lymph  plasma  may  contain  irritating  matter. 


LYMPHATIC  CHANNELS  DRAINING  CERVIX  AND 
VAGINA    (POIRIER) 

Fig.  148.  This  excellent  illustration  demonstrates  the 
facility  with  which  cervical  and  vaginal  carcinoma  (the 
most  prevalent  forms)  may  become  distributed  through  the 
tractus  lymphaticus  annexed  to  the  tractus  genitalis. 


THE  ABDOMIXAL  AXD  PELVIC  BRAIX 


Fig.  149. 

LYMPH  CHANNEL  (A.  A.)  OF  PYLORIC  END  OF 
RABBIT'S  OMEXTERuX 


2.  Deficient  sensation  in 
the  lymphatic  tract  may  be 
due  to  excessive  or  over- 
whelming poisonous  sub- 
stances in  the  lymph  plasma 
or  paresis  (blunted  sensibil- 
ity) of  the  peripheral  nerve 
ending  in  the  endothelium 
(traumatic  paresis  from 
compression  cedemaj.  De- 
ficient bodily  activity  may 
cause  deficient  lymph  flow 
and  consequent  deficient 
sensation. 

3.  Disproportionate  sen- 
sation in  the  tractus  lym- 
phaticus  may  arise  from  an- 
esthesia, hyperesthesia  in 
its  different  segments  and 
also  from  different  composi- 
tion of  lymph  plasma  from 
different  organs.  Also  dis- 
proportional  bodily  muscular 
activity  may  share  producing 
disproportional  sensation. 

II.       PERISTALSIS     (EXCESSIVE, 
DEFICIENT.   DISPROPOR- 
TIONATE). 

4.  Excessive  peristalsis 
may  arise  from  irritating 
lymph  plasma  or  irritation 
of  the  walls  of  the  lymph 
tract  from  supersensitiveness 
of    the    endothelium.      The 

Fig.  149.  A.  A,  is  a  lymph 
channel  from  which  I  penciled  the 
peritoneal  endothelium  and 
stained  with  AgX03-  One  can 
observe  a  dozen  stomata  vera  on 
this  lymph  channel,  directly  com- 
municating with  the  peritoneum. 
Xote  the  sinuous  outline  of  the 
endothelium  composing  the 
lymph  channel.  Parallel  to  this 
lymph  channel  is  a  zone  of  peri- 
toneal endothelium  stained  with 
AgXOs,  presenting  stomata  vera 
S.  V.)  and  endothelium  without 
sinuous  borders. 


TR.  ICTUS   LYMPHATICUS   AND    LYMPH 


525 


lymph  vessels  contract  from  their  own  parietes — no  apparatus  like  the 
heart  propel  their  contents.  Peristalsis  in  the  lymph  channel  is  obvious 
chiefly  in  the  ductus  thoracicus.  The  rate  and  volume  of  lymph  flow 
depends  on  the  rate  and  volume  of  blood  flow,  on  tissue  pressure  and  muscular 
activity.  In  certain  localities  the  lymph  flow  must  depend  on  the  difference 
of  blood  pressure  and  that  of  the  lymph  in  the  tissue.  Obstruction  of  the 
thoracic  duct  would  induce  excessive,  vain  peristalsis  in  the  lymph  channels. 
Extra  distention  of  the  left  subclavian  vein  might  induce  excessive  peristalsis 
in  the  thoracic  duct.  Extraordinary  muscular  activity  may  induce  excessive 
peristalsis. 


TRANSITION  OF  LYMPH  CAPILLARIES  INTO  LYMPH  TRUNKS  WITH  VALVES 

—SACCULATIONS 

Fig.  150.    a,  beginning    of  lymph   trunk;    b,  b,  lymph    reservoirs:  magnified    15    times. 
(Teichman.) 

5.  Deficient  Peristalsis  or  stasis  of  lymph  occurs  in  tissue  with  limited 
elastic  tension.  The  same  condition  favors  venous  stasis.  Also  force  of 
gravity  favors  lymph  stasis.  Hence  general  lymph  oedema  occurs  in  the  ankle 
region  or  lumbao-sacral  region.  The  obstruction  of  a  single  lymph  channel 
(or  vein)  does  not  necessarily  produce  cedema  because  the  lymph  (or  venous 
channel)  may  assume  a  collateral  circulation  from  rich  anastomosis.  Transu- 
dation of  lymph  may  not  produce  cedema  as  the  lymph  may  be  transported 
by  the  lymphatics. 

If  general  venous  stasis  exists  the  blood  pressure  in  the  left  subclavian 
is  raised  and  lymph  cedema  may  be  general  and  peristalsis  of  the  lymphatics 


526 


THE  ABDOMINAL   AXD   PELVIC  BRAIN 


is  vain.  Lymphatic  peristalsis  may  be  deficient  when  the  tissues  adjacent  to 
the  capillaries  have  been  distended  with  consequent  loss  of  elasticity  and 
power  of  contraction.  Diminished  elastic  pressure  of  the  adjacent  tissue  on 
the  lymph  spaces  diminishes  the  rate  of  flow  of  lymph  plasma.  Deficient 
peristalsis  (lymph  flow)  occurs  subsequent  to  tissue  inflammation,  for  the  elas- 
tic tissue  pressure  is  diminished,  paretic. 

6.  Disproportionate  Peristalsis  (flow)  may  be  observed  subsequent  to  dif- 
ferent degrees  and  different  localities  of  tissue  distention  following  oedema 
from  varying  elastic  tissue  pressure.  Subsequent  to  inflammatory  tissue  pro- 
cesses the  adjacent  elastic  tissue  pressure  is  unequal,  nonuniform,  inducing 
lymphatic  peristalsis  or  flow  disproportionate. 


in. 


SECRETION"  (EXCESSIVE,   DEFICIENT,   DISPROPORTIONATE). 


7.  Excessive  secretion  of  lymph  plasma  may  be  manifest  by  oedema,  tis- 
sue fluid  accumulation,  nephritic  cedema.  Excessive  secretion  of  lymph  plasma 
is  difficult  to  discriminate  from  insuffi- 
cient drainage  or  transportation  of 
lymph.  Excessive  secretion  of  lymph 
may  be  found  in  tissue  oedema  and 
especially  in  the  serous  cavities.  In 
nephritic  cedema  (not  accompanied  by 
cardiac  deficiency)  the  excessive  lymph 
collected  in  the  tissue  is  doubtless  due 
to  simple  stasis,  however,  for  our  view, 
the  lymph  is  excessive.  The  nephritic 
oedema  occurs  first  in  the  subcutaneous 
tissue  and  particularly  in  the  tissue 
possessing  limited  elastic  pressure,  e. 
g.,  about  the  ankles  and  dorsal  surface 
of  the  lumbar  and  sacral  regions.  The 
lymph  oedema  may  be  excessive,  lymph 
formation  or  accumulation  being  from 
obstruction  to  its  escape.  The  quan- 
tity of  lymph  which  escapes  from  the 
blood  capillaries  depends  on  the  differ- 
ence in  pressure"  between  the  lymph 
spaces  and  the  blood  capillaries.  Whether  there  be  excessive  lymph  secretion 
or  lymph  stasis — lymph  oedema — it  is  similiar  in  effect.  The  stasis  of  blood  in 
veins  results  in  lymph  stasis — lymph  cedema.  The  organs  or  tissue  become 
most  oedematous  or  swollen  which  possess  the  most  limited  elastic  pressure — in 
fact  exactly  where  venous  stasis  is  at  a  maximum.  The  lymph  stasis  may  be 
local  as  when  a  vein  is  accluded  by  a  thrombosis,  or  general  as  when  a  lung 
or  heart  is  debilitated.  However,  mere  obstruction  of  a  vein  may  not  pro- 
duce lymph  or  venous  stasis  as  circulation  in  the  vein  and  lymph  channels  is 
rich  on  anastomatic  collateral  routes.  An  increased  lymph  transudation  may 
produce  no  lymph  oedema  as  the  lymph  channel  anastomoses  may  transport 


LYMPH  CHANNELS  AND  GLANDS  OF 
THE  MESENTERON  (HORNER) 

Fig.  151.  Subject  dead  from  ascites.  1, 
thoracic  duct  2,  section  of  aorta.  3,  adja- 
cent aortic  glands.  4,  superficial  lympha- 
tics of  intestines.  5,  6,  7,  lymphatic  channels 
and  glands  of  enteron  and  mesenteron. 


Tit  ICTUS   LYMPHATICUS   AND    LYMPH 


52? 


the  excess  of  lymph  sufficiently  rapid  to  equalize  the  lymph  circulation.  If 
there  be  general  venous  stasis  general  lymph  oedema  may  arise  from  rise  of 
blood  pressure  in  the  left  subclavian  vein  obstructing  the  flow  of  lymph  from 
the  thoracic  duct.  Local  lymph  oedema  may  arise  from  previous  extradisten- 
tion  of  tissue  which  consequently  is  deficient  in  elastic  pressure.  It  is  evident 
that  the  elasticity  of  tissue  and  muscular  activity  exercises  a  powerful  influ- 
ence over  the  rate  of  lymph  flow  and  local  accumulation  of  lymph  plasma. 

In  regard  to  the  nephritic  oedema  it  may  be  noted  that  oedema  occurs  in 
parenchymatous  nephritis — not  in  interstitial  nephritis — and  is  no  doubt  due 
to  retention  within  the  body  of  the  watery  portion  of  the  urine.  A  test  of 
this  matter  may  be  made  by  the  ad- 
ministration of  sodium  chloride  (which 
stimulates,  irritates,  excites  renal  epi- 
thelium). In  the  nephritic  oedema  from 
lymph  stasis  less  than  normal  urine  is 
evacuated  and  the  oedema  increases  as 
the  urine  diminishes  and  vice  versa. 
Now,  administer  8  ounces  of  normal 
salt  solution  every  two  hours  8  times 
daily  and  the  urine  will  rapidly  in- 
crease in  quantity  and  clarification, 
resembling  spring  water,  while  the 
oedema  will  diminish.  It  must  be  well 
borne  in  mind  that  sodium  chloride 
irritates,  damages  inflamed  renal  epi- 
thelium, hence  should  not  be  admin- 
istered in  parenchymatous  nephritis. 
Hammerschlag  has  shown  that  patients 
with  parenchymatous  nephritis  possess 
diluted  blood — an  hydraemia  or  hydrse- 
mic  plethora.  No  doubt  some  dam- 
age, lesion,  exists  in  the  capillary 
wall  in  nephritic  oedema,  because 
the  heart  shares  in  the  process  by 
presenting   hypertrophy.     Dr.    A.   \V. 

Howlett  asserts  that  nephritic  oedema  apparently  depends  in  some  subjects 
on  excess  of  sodium  chloride  within  the  body,  i.  e.,  the  subject  secretes  defi- 
cient quantities  of  sodium  chloride  on  account  of  kidney  defects  (parenchyma- 
tous nephritis)  which  in  turn  necessitates  an  accumulation  of  fluids  (lymph 
within  the  tissues).  Whatever  the  exact  factors  be  I  am  distinctly  convinced 
during  the  past  decade  as  regard  the  action  of  sodium  chloride  on  renal  epithe- 
lium (irritation,  excessive,  or  deficient  secretion),  that  profound  effects  are 
exercised  on  the  kidneys  by  the  amount  of  sodium  chloride  ingested.  So-called 
Indurated  lymph  oedema  occurs  subsequent  to  extirpation  of  the  lymph  gland 
in  a  territory  of  considerable  dimension. 

8.  Deficient  secretion  of  lymph  plasma  is  difficult  to  demonstrate,  although 


LYMPHATIC     DRAINAGE     OF     DIA- 
PHRAGM 

Fig.  152.  The  centrum  tendineum  of  the 
diaphragm  is  drained  by  lymph  trunks — two 
anterior  and  two  posterior  (3,  3,) — which 
terminate  in  the  thoracic  duct  5,  5,  valves  of 
lymphatic  trunks.  D,  D,  thoracic  duct.  6. 
7,  8,  dilated  lymph  spaces  in  the  diaphragm. 
The  dark  circular  disc  represents  the  point 
of  the  central  tendineum  where  the  heart 
rests,  in  which  disc  there  are  no  lymph 
spaces. 


528 


THE  ABDOMINAL   AND   PELVIC  BRAIN 


it  undoubtedly  occurs  especially  where  tissue  is  dense  and  hence  where  little 
lymph  will  escape,  however,  in  atrophic  tissue  doubtless  deficient  lymph  is 
secreted. 

9.  Disproportionate  secretion  of  lymph  is  evident 
in  different  regions  of  the  body.  The  resistence  offered 
by  the  different  degrees  of  tissue  elasticity  and  pres- 
sure accounts  for  its  share.  Also  the  lymphatics  are 
unequally  distributed.  The  erect  attitude  presents 
disproportionate  lymph  secretion  from  force  of  grav- 
ity. In  the  erect  attitude  the  force  of  gravity  exposes 
extra  tissue  pressure  in  certain  localities,  as  the  ankle 
and  foot  region. 

IV.       ABSORPTION     (EXCESSIVE,     DEFICIENT, 
DISPROPORTIONATE) . 


10.  Excessive;  11,  deficient;  12,  disproportionate, 
absorption  of  lymph  plasma  is  difficult  to  demonstrate 
and  time  and  space  here  forbids. 

THE    DIAGNOSIS    OF    PATHOLOGIC    PHYSIOLOGY    IN  THE 
TRACTUS  LYMPHATICUS. 


PROFILE    VIEW     OF 

THE     DUCTUS 

THORACICUS 

Fig.  153.  1,  the  cervi- 
cal dilatation  of  the  thor- 
acic duct  terminating  in 
the  left  subclavian  vein. 
2,  the  isthmus  of  the  thor- 
acic duct  in  the  dorsal 
region.  3,  receptactdum 
lymphatica. 


For  rational  views  and  practical  purposes  defi- 
nite ideas  should  be  entertained  of  the  functions  of 
an  organ.     It  is  evident  that  to  the  tractus  lymphat- 

icus  the  four  common  visceral  functions  (sensation,  peristalsis,  absorption, 
secretion)  belong.  When  these  four  functions  of  the  tractus  lymphaticus 
pursue  a  normal    course    there    is   no    pathologic    physiology — no    disease 

exists — and  no  correction  of  func- 
tion or  therapeusis  is  demanded. 
As  water  basins  are  the  great  centers 
of  civilization,  so  the  lymph  channel 
is  the  great  center  of  nourishment. 
In  both  instances  it  is  the  facility 
of  a  transporting  fluid  medium  which 
accomplishes  the  object.  The  sig- 
nification of  the  tractus  lymphaticus 
is  evident  when  it  is  realized  that  it 
is  the  highway  of  cell  nourishment 
and  cell  drainage.  Along  the  bor- 
ders of  the  great  lymph  stream  every 
cell  is  a  harbor  for  import  and  export 
service.  The  object  of  the  tractus 
LYMPH  CHANNELS  IN  THE  PERI-  lymphaticus  is  universal  cell  nour- 
TONEUM  ishment  and  universal  cell  drainage. 

Fig.  154.     The  lymph  vessels  present  elon-      Pathologic  physiology  of  the  tractus 
gated  endothelium,  valves,  dilatation  and  con-  ,       .  .      ,  . 

struction.  lymphaticus  is  the  zone  between  nor- 


TRACTUS   LYMPHATICUS   AND    LYMf'll 


529 


mal  physiology  and  pathologic  anatomy  and  should  be  amenable  to  therapeu- 
tics. Pathologic  physiology  will  constitute  a  useful  field  for  the  cultivation 
of  physiology,  diagnosis,  therapeutics,  rational  practice  and  prophylaxis. 
As  the  tractus  lymphaticus  is  of  vast  utility  in  the  animal  economy,  having 
an  import  service  (transportation  of  cell  nourishment)  and  an  export  service 
(transportation  of  cell  drainage),  its  pathologic  physiology  comprises  a  cor- 
respondingly extensive  zone.  Pathologic  physiology  in  the  tractus  lymphati- 
cus is  disordered  or  abnormal  function,  the  beginning  of  disease.  Pathologic 
anatomy  is  a  disordered  or  abnormal  structure,  the  establishment  of  disease. 
Disease  begins  as  abnormal  function  and  its  progress  consists  in  a  repetition 
of  the  abnormal  or  deviating  physiology.     Modern  radical  surgery  in  tubercu- 


LYMPHATICS  FROM  ENTERON  OF  GUINEA  PIG  WITH  PLEXUS  MYENTERI- 

CUS  OF  AUERBACH  (FREY) 

Fig.  155.  a,  b,  a,  b,  Auerbach's  Plexus  (Plexus  myentericus)  ;  c,  narrow  and  d,  larger  lymph 
channels.  This  excellent  illustration  demonstrates  the  intimate  relation  of  the  rich  plexuses 
of  the  nervus  vasomotoiius  and  rich  plexuses  of  the  vasa  lymphatica. 


losis  and  carcinoma  depends  for  its  sucess  on  a  knowledge  of  the  anatomic 
distribution  of  the  lymph  channels  and  glands.  The  pathologic  physiology 
in  the  lymphatic  glands  and  channels  may  suggest  a  diagnosis  by  leading  the 
physician  to  a  local  lesion  along  their  route  as  enlarging  inguinal  glands  may 
indicate  a  genital  or  rectal  lesion,  they  may  lead  to  the  discovery  of  septic 
foci  or  solutions  of  continuity  in  distant  regions,  e.  g.,  an  infected  foot,  a 
corn,  a  bunion.  A  rising  pathologic  physiology  in  the  axillary  glands  may 
enable  the  physician  to  diagnose  advancing  carcinoma.  The  location  of  the 
lymphatic  glands  and  the  route  of  the  lymphatic  channels  are  the  essentials 
in  the  diagnosis.  This  is  strikingly  manifest  in  the  phenomena  that  extensive 
removal  of  lymph  glands  may  result  in  induration  of  lymph  oedema.  The 
anatomy  is  the  solid  ground  to  determine  the  direction  of    lymph  channels 


530 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


and  location  of  lymph  glands.  Lymph  glands  enlarge  generally  from 
bacterial  disease,  carcinoma  or  sarcoma.  Enlarging  lymph  glands  herald  the 
advance  of  disease.  The  tractus  lymphaticus  stands  as  a  sentinel  on  guard 
over  normal  bodily  nourishment.  It  niters  and  checks  the  deleterious  and 
poisonous  substance  from  gaining  access  to  the  parenchymatous  cell.  The 
lymph  glands  imprison  inert  substance 
and  the  carcinomatous  cell,  retarding 
the  progress  of  carcinoma.  The  de- 
tectable route  of  the  most  implacable 
and  deadly  enemy  of  man— carcinoma 
— is  through  the  tractus  lymphaticus. 
The  early  detection  and  treatment  of 
the  precarcinomatous  stage  must  be 
accomplished  by  the  recognition  of 
pathologic  physiology  of  the  tractus 
lymphaticus.  The  lymph  system  pre- 
sides as  a  tissue  inspector  and  protector. 
It  digests,  imprisons,  sterilizes  in  the 
interest  of  the  general  organism.  The 
lymph  plasma  possesses  a  body  guard 
in  its  guest — the  army  of  leucocytes. 

RELATIONS    OF    THE    TRACTUS    LYMPHAT- 
ICUS   TO    PRACTICAL    MEDICINE. 

Clinicians  are  recognizing  the  nu- 
merous relations  of  the  lymphatic  sys- 
tem to  practical  medicine  and  surgery. 
Metastatic  manifestations,  both  bac- 
teriologic  and  neoplastic,  extend 
through  definite  routes  of  lymph  chan- 
nels and  their  associated  glands,  and 
the  object  of  pathologic  physiology 
is  to  detect  the  process  in  ample  time 
to  save  the  organism  from  destruc- 
tion by  establishing  irreparable  pa- 
thologic anatomy.  Armed  with  a 
knowledge  of  the  physiology  of  the 
tractus  lymphaticus  and  its  topo- 
graphic anatomy  the  physician  is  fore- 
warned as  to  its  course  of  incipient 
pathologic  physiology  and  considera- 
tions of  rational  treatment  should  engage  his  attention.  First  and  fore- 
most the  luxuriant  anastomoses  of  the  lymph  channels  appear  to  allow 
bacterial  or  carcinomatous  material  to  avoid  attacking  certain  lymph  glands 
in  the  route  of  the  lymph  channels.  In  other  words  the  bacterial  or  carcino- 
matous material  may  not  attack  lymphatic  glands  in  the  direct  order  of  their 


RECTAL  GLANDS  AND  LYMPHATICS 

Fig.  15&  This  figure  illustrates  the  route 
of  carcinomatous  or  other  infectious  mate- 
rial through  the  numerous  rectal  lympha- 
tics and  glands  (Gerota). 


TRAC  TUS    LYMPHATICUS    AND    LYMPH 


531 


channels  and  topographic  course.  The  lymph  channels  are  so  richly  anas- 
tomosed that  the  course  of  the  lymph  current  may  be  direct  or  reverse.  Dr. 
Emil  Ries  has  demonstrated  this  view  as  regards  carcinoma  in  the  route  of 
the  tractus  lymphaticus  draining  the  tractus  genitalis.  Again  the  physician 
is  unable  to  decide  macroscopically  whether  a  lymph  gland  is  hypertrophied 
from  bacterial  or  carcinomatous  infection.  Hence  from  abundant  anastomoses 
of  lymph  channels,  thrombotic  or  other  obstruction  may  induce  metastatic 
manifestations  in  lymph  tracts  not  primarily  involved.  The  extensive 
removal  of  lymph  channels  and  glands,  as  those  of  the  axilla  for  carcinoma  of 
the  mamma,  seldom  produces  lymph  oedema  or  stasis  because  the  luxuriant 
anastomoses  of  lymph  channels 
allow  the  lymph  to  flow  in  multi- 
ple directions.  The  tractus  mus- 
cularis  through  its  activity,  its 
massage,  exercises  a  wonderful 
influence  over  the  flow  of  the 
lymph.  In  states  of  bodily  re- 
pose the  respiratory  muscles  pur- 
sue continuous  rhythmical  motion 
maintaining  continuous  lymph 
flow.  A  comprehensive  view  of 
drainage  may  be  secured  by  a 
study  of  the  tractus  lymphaticus, 
as  cells  are  nourished  and  drained 
by  the  lymph  fluid.  A  lympha- 
gcgue  is  an  agent  which  increases 
the  flow  of  lymph.  Lymph  in- 
creases its  rate  of  flow  under  the 
influence  of  pilocarpin,  ergotine. 
The  rate  of  flow  of  any  fluid 
depends  on  its  consistency.  The 
consistency  of  the  lymph  depends 
on  the  quantity  of  fluid  injected. 
Drainage  and  nourishment  of  cells 
depends  on  the  rate  of  lymph 
flow  as  well  as  on  its  quantity 
and  quality.  The  degree  of  muscular  activity  or  massage  determines  relatively 
the  rate  of  lymph  flow.  Muscular  activity  or  massage  increases  the  cardio- 
vascular action  and  consequently  the  blood  pressure  is  elevated.  We  fre- 
quently observe  lymph  oedema  in  the  abdominal  wall  in  subjects  with  large 
abdominal  tumor.  Here  the  lymph  accumulates  in  dependent  tissue  with 
deficient  elasticity,  and  pressure  or  mechanical  obstruction  occurs.  The  blood 
pressure  within  the  artery  is  tenfold  greater  than  the  blood  pressure  within 
the  vein  and  complete  circulation  of  the  blood  requires  less  than  a  minute. 
Hence  the  venous  pressure  is  vastly  greater  than  that  of  the  lymphatics,  how- 
ever, experiments  demonstrate  that  the  lymphatic  circulation  is  vigorous  and 


STOMATA  VERA  CONNECTING  THE  PER- 
ITONEUM WITH  THE  SUBPERITONEAL 
LYMPH  CHANNELS 

Fig.  157.  From  rabbit's  omentum.  The 
endothelium  was  brushed  away  and  the  base 
stained  with  l/z  per  cent  of  AgN03  and  haema- 
toxylin.  The  stomata  vera  (s.  v.,  9  of  them)  are 
patent  channels,  communicating  tubes,  connecting 
the  peritoneum  with  the  sub-peritoneal  lymph 
spaces  and  vessels. 


532 


THE  ABDOMINAL  AXD   PELVIC  BRAIN 


rapid,  e.  g.  salt  solution  injected  in  the  connective  tissue  (as  beneath  the 
mammae)  rapidly  enters  the  blood  circulation. 

TREATMENT    OF    PATHOLOGIC    PHYSIOLOGY    OF    THE    TRACTUS   LYMPHATICUS   AND 

THE  LYMPH. 

In  general  T\  of  illness  or  complaints  is  pathologic  physiology — disordered 
function — and  to  is  surgery — pathologic  anatomy — disordered  structure. 
Modern  research  is  re-instating 
rational  therapeutics,  i.  e.,  the  cor- 
rection of  disordered  function. 
Practically  the  field  of  influence  and 
utility  of  a  physician  is  limited  to 
the  zone  of  pathologic  physiology 
(which  lies  between  physiology  and 
pathologic  anatomy).  The  chief 
duty  of  the  physician  is  to  restore 
function.  The  deviating  functions 
to  restore  in  pathologic  physiology 
of  the  tractus  lymphaticus  are  sen- 
sation, peristalsis,  absorption,  secre-  %LX 
tion.  Pathologic  physiology  of  the 
tractus  lymphaticus  is  best  corrected 
and  normal  function  maintained  by 
natural  methods  or  rational  thera- 
peutics. The  rational  agent  of 
therapeutics  for  the  treatment  of 
pathologic  physiology  of  the  tractus 
lymphaticus  are:  I,  Fluids;  II, 
Food;  III,  Habitat;  1Y,  Avocation; 
V,  Drugs;  VI,  Surgery;  VII,  Mis- 
cellaneous. 

Since  pathologic  physiology  of 
the  tractus  lymphaticus  is  the  zone 
between  physiology  and  pathologic 
anatomy  it  should  be  amenable  to 
treatment.  In  the  treatment  of  pa- 
thologic physiology  of  any  abdom- 
inal visceral  tract  it  must  be  remem- 
bered that  the  half  dozen  visceral 
tracts  normally  functionate  in  per- 
fect harmony — no  friction — and  if 
any  one  tract  be  disordered  the  ex- 
quisite physiologic  balance  of  all  is 

disturbed.  The  pathologic  physiology  of  the  tractus  lymphaticus  is  treated 
mainly  indirectly,  i.  e.,  through  the  influence  of  other  visceral  tracts,  e.  g., 
(1)   the   tractus  vascularis   must   be   restored   to   normal   as  to   composition 


LYMPH  GLAND  WITH  VASA  EFFEREN- 
TIA    ET    AFFERENTIA    (TOLDT) 

Fig.  158.  A  schematic  illustration  of  a 
lymphatic  gland  with  the  entering  vessels  (vasa 
efferentia,  7)  and  departing  vessels  (vasa  affer- 
entia,  11).  9  points  to  the  stroma  in  trie  hilum.  4, 
substantia  corticalis.  1  and  5,  connective  tis- 
sue capsule.  6,  surface  of  lymph  tract.  Observe 
that  in  the  region  of  9  and  10  are  afferent  and 
efferent  vessels  anastomoses  without  first 
entering  the  gland. 


TRACTUS   LYMPHATICUS   AXD    LYMPH 


533 


(blood,  plasma,  oxygen)  and  pressure  (cardio-vascular  function  must  be 
normal;  venous  flow  depends  on  arterial  blood  pressure);  e.  g.,  (2)  the  tractus 
muscularis  must  functionate  normally  (lymph  largely  depends  on  muscular 
activity,  on  respiration,  condition  of  veins).  The  pathologic  physiology  of 
any  viscus  is  frequently  restored  by  stimulating  the  four  common  functions 
of  other  viscera  (sensation,  peristalsis,  absorption,  secretion). 

I.       VISCERAL  DRAINAGE  BY  FLUID. 

The  most  useful  and  safe  diuretic  is  water.     It  is  the  natural  functionat- 
ing medium  for  the  kidney.     One  of   the  best    laxatives   is    water.     Thirst 
is   nature's   demand    for   fluid. 
Water  is  the  most   important  1^  ^0 

constituent  of  protoplasm,  com- 
prising some  70  per  cent  of  it. 
I  was  a  watcher  of  Dr.  Tanner 
25  years  ago  when  he  lived  40 
days  on  water  alone — without 
food.  However,  a  few  days 
without  water  is  imminently 
fatal.  The  quantity  of  water 
required  by  the  organism  varies 
with  the  quantity  eliminated. 
The  quantity  of  water  elimi- 
nated, approximately,  by  a  sub- 
ject of  150  lbs.  at  rest,  is  for 
the  tractus  urinarius  45  ounces, 
for  the  tractus  respiratorius  12 
ounces,  for  the  tractus  per- 
spiratorius  8,  for  the  tractus 
intestinalis  5  ounces — a  total 
elimination  of  70  ounces,  al- 
most 5  pints  of  fluid.  It  will 
therefore  require  two  quarts  for 
the  demands  of  elimination  or 
to  satisfy  living  functionation. 
Many  subjects  do  not  drink 
over  three  pints  daily  and  that 
is  administered  chiefly  at  meal 
time,  not  only  burdening  the 
tractus  intestinalis  with  solid 
food,  but  fluid  also.  Many  subjects  drink  insufficiently  and  suffer  consequent 
oliguria,  deficient  drainage.  Such  subjects  are  burdened  with  waste  laden 
blood,  inflicting  irritation  and  trauma  on  the  nerve  periphery.  They  are  in 
conflict  with  their  own  secretions.  Many  women  oppose  free  drinking  from 
the  idea  it  creates  fat. 

Ample  quantities  of  fluid  at  regular  intervals  is  the  safety  valve  of  health 


LYMPHATICS  OF  AXILLA  AND   MAMMA 

Fig.  159.  This  illustration  demonstrates  the 
course  of  infectious  material  or  carcinoma  from 
mamma  to  axillary  glands.  The  tractus  lymphaticus 
possesses   numerous   channels    with    ample  lumen. 

(Sappey.) 


534 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


and  capacity  for  mental  or  physical  labor.  Ample  fluids  not  only  flush  the 
sewers  of  the  body,  but  wash  the  internal  tissues  and  tissue  spaces,  relieving 
waste  laden  blood.  The  soluble  matter  and  salts  are  not  only  dissolved  (pre- 
venting calculus,  trauma  and  in- 
fection) and  eliminated,  but  the 
insoluble  matter  and  salts  are 
floated  from  the  system,  relieving 
waste  laden  blood  by  such  power- 
ful streams  of  fluid  that  calculus 
is  not  liable  to  be  formed.  One 
of  the  most  effective  and  natural 
stimulants  to  the  renal  epithelium 
is  sodium  chloride.  (Note — 
Sodium  chloride  should  not 
be  employed  in  parenchymatous 
nephritis.)  For  ten  years  I  have 
diluted  the  urine,  increased  its 
volume  (consequently  increased 
ureteral  peristalsis)  and  clarified 
it  by  administering  8  ounces  of 
^2  or  34  normal  salt  solution  six 
times  daily.  I  have  manufac- 
tured sodium  chloride  tablets  (12 
gr.  each  with  flavor).  The  pa- 
tient places  on  the  tongue  a  half 
tablet  (NaCl)  and  drinks  a  glass- 
ful of  water  (better  hot)  before 
each  meal.  This  is  also  repeated 
in  the  middle  of  the  forenoon  (10 
A.  M.),  middle  of  the  afternoon 
(3  P.  M.),  and  at  bedtime  (9  P. 
M.).  The  patient  thus  drinks  3 
pints  of  (/{  to  Y*)  normal  salt 
solution  daily.  This  practically 
renders  the  urine  normal,  and  acts 
as  ample  prophylaxis  against  the 
formation  of  urinary,  hepatic, 
pancreatic,  faecal  calculus,  and 
drains  the  body  of  waste  material. 
The  formation  of  calculus  cannot 
occur  when  ample  fluid  in  vig- 
orous streams  bathe,  flood  the 
glandular  exit  canals.  With  a 
deficient  fluid  stream,  crystals 
form  a  calculus  with  facility. 
The  maximum  concentrated  solu- 


DUCTUS     THORACICUS,      SINISTER      ET 
DEXTER  (TOLDT) 

Fig.  ICO.  This  illustrates  well  the  terminating 
lymph  trunks  as  an  anastomosing  network  on  the 
dorsal  wall.  Note  :  (a)  the  isthmus  of  the  thoracic 
duct  (at  its  middle  portion,  27);  (b)  the  recep- 
taculum  lymphatica  (25)  at  its  distal  end ;  (c)  the 
thoracic  dilatation  or  ampulla  at  its  proximal  end. 


TRACTUS   LYMPHATICUS    AND    LYMPH 


535 


tion  of  urine,  bile  or  pancreatic  juice  tends  to  crystallize  with  vastly  more 
facility  than  dilute  urine,  bile  and  pancreatic  juice.  In  "visceral  drainage" 
single  crystals  on  first  formation  are  rapidly  floated  with  facility  by  the  ample 
fluids  present,  while  by  diminutive  quantities  of  fluid,  and  consequently  aggre- 
gation, the  crystals  tend  to  precipitate,  lodge,  accumulate  and  form  calculus. 
Oliguria  is  a  splendid  base  for  calculus  formation  in  the  ureter.  For  over 
ten  years  I  have  been  using  sodium  chloride,  normal  salt  solution,  more  or 
less  in  my  practice.  During  that  time  some  practical  clinical  views  have 
been  demonstrated  and  repeated  so  frequently  that  they  have  become  estab- 
lished, I  think,  beyond  the  shadow  of  doubt.  The  following  propositions 
have  been  repeatedly  demonstrated  hundreds  of  times — during  the  last  ten 
years — in  the  clinics  of  Dr.  Lucy  Waite  and  mine  and  in  our  surgical  opera- 
tions that  I  shall  consider  them  established 
until  otherwise  disproven : 

1.  Sodium  chloride  (Y  to  Y  normal 
physiologic  salt  solution)  is  a  powerful  stim- 
ulant to  the  renal  epithelium  (tractus  urina- 
rius). 

_.  The  administration  of  8  ounces  of  Y* 
to  %  normal  physiologic  salt  solution  (better 
hot)  every  two  hours  for  six  times  daily  will 
increase  the  quantity  and  clarify  the  urine, 
by  diluting  its  color  and  salts  making  it 
appear  almost  like  spring  water  in  3  to  5 
days.  (Note — Sodium  chloride  should  not 
be  administered  in  parenchymatous  ne- 
phritis— not  in  fluid  or  food — as  it  exacer- 
bates, irritates,  the  diseased,  inflamed 
parenchymatous  cell.) 

8.  Sodium  chloride  (in  Y*  to  %  normal 
physiologic  solution)  is  a  vigorous  stimulant 
to  the  epithelium  of  the  tractus  intestinalis 
and  its  appendages.  Normal  salt  solution 
is  an  excellent  remedy  to  quench  thirst 
subsequent  to  peritonotomy  by  rectal  lavage — a  pint  every  hour. 

4.  Sodium  chloride  is  vigorously  active  stimulant  to  (glandular)  epithe- 
lium as  that  of  the  tractus  urinarius,  intestinalis,  genitalis,  cutis  respiratorius, 
salivary,  hepatic  and  pancreatic  glands.  It  stimulates  the  four  common  vis- 
ceral functions — sensation  peristalsis,  absorption,  secretion.  It  is  a  natural 
stimulant  (to  epithelium  and  endothelium)  as  it  constitutes  over  Yi  of  1  per 
cent  of  the  blood.  The  lymph  plasma  arises  from  the  blood  plasma.  What- 
ever dilutes  the  blood  plasma  will  therefore  dilute  the  lymph  plasma.  Eight 
ounces  of  partial  normal  salt  solution  6  times  daily  will  increase  the  blood 
volume  and  consequently  increase  the  lymph  volume  which  will  irrigate,  flush 
the  lymph  spaces  and  wash  the  cells.  Also  increased  blood  volume  increases 
the  pressure  or  rate  of  lymph  flow,  perfecting  visceral  drainage.     Since  the 


PERIVASCULAR       LYMPHATIC 
(GEGENBAUER) 

Fig.  161.  A,  perivascular  lympha- 
tic of  the  turtle's  aorta.  B.  cross  sec- 
tion of  an  artery  from  the  cerebrum 
presenting  perivascular  lymph  spaces 
divided  by  partitions.  It  is  known 
as  the  perivascular  lymph  space  of 
His.  The  Virchow-Robin  space  is 
the  lymph  space  in  the  adventitia  of 
blood  vessel  wall. 


536 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


lymph  plasma  contains  not  only  the  nourishment  for  the  cells  but  also  the 
waste  product  of  the  cell  the  drainage  of  the  tractus  lymphaticus  should  be 
rather  excessive  than  deficient  as  the  abundant  fresh  nourishment  vitalizes, 
energizes  the  cell.  Cell  function  is  performed  through  a  fluid  medium,  hence 
water,  which  is  a  fluid  transporter,  a  solvent,  an  eliminator  and  regulator  of 
temperature,  is  first  and  foremost  essential  in  the  pathologic  physiology  of 
the  tractus  lymphaticus.  We  live  in  a  fluid  medium  and  elimination  demands 
a  compensatory  supply  so  that  the  cells  may  continue  their  submerged  aqua- 
tic life.  Living  cells,  which  is  life,  will  persist  in  a  fluid  medium  only. 
Ample  water  drinking  affords  a  bath  for  the  cells.  Absorption  of  fluids  from 
the  tractus  intestinalis  is  especially  stimulated  by  NaCl  and  C02,  i.  e.,  nor- 
mal salt  solution  surcharged 
with  carbonic  acid  gas  passes 
into  the  tractus  vascularis 
and  consequently  in  the 
tractus  lymphaticus  the  most 
rapidly  of  any  fluid. 

Sodium  chloride  is  the 
most  important  inorganic 
salt  in  the  body,  e.  g.,  blood 
plasma  contains  0. 7  per  cent ; 
lymph  plasma  contains  0.6 
per  cent;  saliva  contains  0.8 
percent;  gastric  secretions 
0.2  per  cent;  pancreatic  se- 
cretions 0.3  per  cent;  bile 
contains  0.7  per  cent;  mus- 
cle contains  0.7  per  cent; 
cerebro-spinal  fluid  contains 
0.5  per  cent;  milk  contains 
0.23  per  cent;  cedematous 
contains  0.8  per  cent.  So- 
dium chloride,  being  univer- 
sally distributed  in  the  body, 
plays  some  role  of  maximum 
importance  in  the  animal  economy.  Sodium  chloride  maintains  the  body 
solutions  at  a  fixed  density,  therefore  maintaining  the  body  tissue  at  a 
proper  percentage  of  water.  It  maintains  blood  plasma  density  in  order  to 
suspend  red  corpuscles,  and  lymph  plasma  density  in  order  to  maintain  in 
suspension  the  guests — white  blood  corpuscles.  Cattle  breeders  know  that 
a  herbivora  will  not  thrive  well  without  a  certain  quantity  of  NaCl.  Deer 
will  travel  miles  to  frequent  the  "lick."  Carnivora  secure  sufficient  NaCl 
from  their  food. 

NaCl  is  required  for  a  stimulus  to  muscular  contraction.  NaCl  is  of  spe- 
cial value  to  digest  vegetables  (vegetarians).  NaCl  plays  a  maximum  role  in 
the  physiology  of  the  animal  economy.     Its  elimination  from  diet  produces 


SUPERFICIAL(SMALLER)  AND  DEEP  (LARGER) 
ANASTOMOSING  LYMPHATICS 

Fig.  162.  From  the  skin  of  a  child's  scrotum.  This 
cut  demonstrates  the  magnitude  and  importance  of  the 
lymphatic  apparatus.     (Teichman.) 


TRACTUS   LYMPHATICUS   AND    LYMPH 


:,::: 


pathologic  conditions.  In  parenchymatous  nephritis  it  should  be  adminis- 
tered in  a  minimum  quantity  as  it  excessively  stimulates  the  inflamed  renal 
cell.  For  further  details  regarding  NaCl  see  Dr.  Herbert  Richardson,  Amer- 
ican Medicine,  July,  1906. 

The  power  of  rapidly  absorbing  water  in  the  tractus  intestinalis  is  in  the 
following  order,  viz.:  (a)  absorption  is  rapid  and  vigorous  in  the  enteron; 
(b)  absorption  is  moderately  rapid  and  vigorous  in  the  colon — (however  I 
have  observed  a  pint  an  hour  absorbed  per  rectum  and  sigmoid);  (c)  absorp- 
tion occurs  slowly  and  moder- 
ately in  the  stomach.  Ample 
water  inhibited  at  regular  in- 
tervals serves  as  a  medium  for 
prompt  conveyance  of  nourish- 
ment to  the  cells.  It  acceler- 
ates the  current  of  the  blood 
and  lymph  plasma — at  once 
promptly  nourishing  and  drain- 
ing the  cells.  Ample  fluids  at 
regular  intervals  increase  the 
volume  and  rate  of  blood  flow, 
hence  circulation  is  more  rapid 
and  thus  the  blood  absorbs 
more  oxygen  in  a  definite  time 
to  be  transported  in  life  to  the 
tissue.  Visceral  drainage  fur- 
nishes a  maximum  nourishment 
and  drainage  to  cells  and  hence 
furnishes  a  maximum  vitality 
to  the  organism.  In  patho- 
logic physiology  of  the  tractus 
lymphaticus — as  in  tissue  oede- 
ma or  "dropsies" — ample  fluids 
(carbonated  normal  salt  solu- 
tion) at  regular  intervals  are 
beneficial,  producing  rapid  re- 
lief, from  extrarenal,  cutaneous 
and  intestinal  elimination.  In- 
sufficient fluid  ingesta  makes 
the  body  resemble  a  stagnant 
pool,  while  ample  fluid  ingesta  invigorates  it  to  a 
is  a  vital  stimulant  for  cell  function. 


LYMPHATICS  AND  GLANDS  OF  THE  MESEN- 
TERON 

Fig.  163.  This  figure  represents  excellently  the 
relation  of  the  mesenteronic  lymphatics  and  glands 
to  the  vasa  mesenterica.  The  several  tiers,  rows  of 
mesenteronic  lymphatic  glands,  present  characteris- 
tic hypertrophy  in  pathologic  physiology  of  tractus 
lymphaticus  associated  with  the  enteron.     (Henle.) 


mountain  stream.     Water 


(b)  visceral  drainage  by  food. 

To  drain  viscera  by  appropriate  food  may  sound  paradoxical,  but  75%  of 
food  is  fluid  and  both  solid  and  fluid  ingesta  excite  the  four  grand  common 
visceral  functions  of    the  tractus   lymphaticus,    viz.,  sensation,   peristalsis, 


53S 


THE   ABDOMIXAL   AXD   PELVIC  BRA IX 


absorption,  secretion,  which  are  initiated,  maintained  and  subside  by  fluid 
and  food.  The  appropriate  food  produces  the  appropriate  degree  of  sensa- 
tion, peristalsis,  absorption,  secretion  in  the  tractus  intestinalis  for  function- 
ation.  The  food  that  will  induce  proper  sensation,  peristalsis,  absorption 
and  secretion  is  that  which  leaves  a  maximum  indigestible  residue  to  stimulate 
the  enteron  and  colon,  such  as  cereals  and  vegetables  Peristalsis  is  neces- 
sary for  secretion,  for  peristalsis  massages  the  secretory  glands  in  the  tractus 
intestinalis,  enhancing  secretory  activity.  The  question  of  diet  to  determine 
is:  (a)  what  kind  of  food  causes  calculus-producing  material  in  the  urine, 
pancreatic  secretion  or  bile?    (b)  what  kind  of  food  influences  the  solubility 


_i£if-.« 


THE    INGUINAL  GLANDS    RECEIVING   THE    RECTAL   AND   GENITAL   LYMPH 

CHANNELS   (TOLDT) 

Fig.  164.  This  figure  demonstrates  that  rectal  or  genital  infectious  or  c^r' inomatous 
material  will  be  transported  to  the  inguinal  glands — hence  the  hypertrophy  ard  tenderness 
of  the  inguinal  glands  are  indicators  of  pathologic  physiology  in  the  genitals  and  re:tum. 


of  the  calculus-producing  material  in  the  urine,  pancreatic  secretion  or 
bile?  (1)  The  meat  eater  is  the  individual  with  the  maximum  quantity 
of  free  uric  acid  in  the  urine.  Flesh  is  rich  in  uric  acid.  Hence,  in 
excess  of  uric  acid  in  the  urine,  flesh  (meat,  fish,  and  fowl  are  all  about 
equal  in  power  to  produce  uric  acid)  should  be  practically  excluded, 
because  it  increases  free  uric  acid  in  the  urine,  e.  g.,  the  rational  treatment 
of  excessive  uric  acid  in  the  urine  consists  of  administering  food  that  contains 
elements  to  produce  basic  combinations  with  uric  acid,  forming  urates  (usually 
sodium)  which  are  free  soluble,  this  will  diminish  the  free  uric  acid  in  the 
urine.     Excessive  uric  acid  in  the  urine  is  an  error  in  metabolism.     Flesh 


TRACTUS   LYMPHATICUS   AND    LYMPH 


539 


eaters  have  uric  acid  and  stone.  Vegetarians  have  phosphate,  oxalate  stone. 
Generally  the  subject  who  suffers  from  uric  acid  is  a  generous  liver,  liberally 
consuming  meat  and  highly  seasoned  foods,  indolent  and  sedentary  persons, 
and  alcoholic  indulgers.     33%  of  uric  acid  is  nitrogen.     Uric  acid  is  derived 


\ 


S^^U 


LYMPH     GLANDS     AND     CHANNELS     RELATING     TO     MAMMA     AND     NECK 

(TOLDT) 
Fig.  165.     This  illustration  demonstrates  the  relation  of  the  mamma  to  the  axillar -y 'glands 
and  subclavicular  glands.     This  is  especially  important  in  pathologic  Physlol°g>  °f 'h*  r,?£  ~ 
of  infectious  and  carcinomatous  material.     It  is  evident  that  the  only  hope  in  controlling 
carcinoma  is  by  observing  its  pathologic  physiology  in  the  precarcinomatous  stage. 


540 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


from  the  nuclei  that  form  a  constituent  of  all  cell  nuclei  and  which  are  taken 
in  the  body  as  food.  Beef  bouillon  may  be  administered  because  the  extract 
matters  in  it  will  scarcely  increase  the  uric  acid.  A  general  meat  diet  largely 
increases  the  free  uric  acid  in  the  urine.  (2)  The  food  should  contain  matters 
rich  in  sodium,  potassium  and  ammonium,  which  will  combine  as  bases  with 
uric  acid,  producing  alkaline  urates  that  are  perfectly  soluble  in  the  urine. 

These  typic  foods  are  the  vegetables  which  not  only  render  the  necessary 
alkalies  to  reduce  and  transform  the  free  uric  acid  into  resulting  soluble 
urates,  but  leave  an  ample  indigestible  faecal  residue  to  cause  active  intestinal 
peristalsis,  aiding  in  the  evacuation 
through  the  digestive  tract.  Hence, 
the  patient  should  consume  large, 
ample  quantities  of  cabbage,  cauli- 
flower, beans,  peas,  radishes,  tur- 
nips, spinach  in  order  that  sodium, 
potassium  and  ammonium  existing 
in  the  vegetable  may  combine  as 
bases  with  free  uric  acid  in  the  urine- 
producing  soluble  urates,  thus 
diminishing  free  uric  acid.  A  veg- 
etable diet  diminishes  the  free  uric 
acid  in  the  urine  35%  less  than  a 
meat  diet.  Again  the  administration 
of  eggs  and  milk  (lactoalbumen)  lim- 
its the  production  of  uric  acid.  The 
most  rational  advice  is  to  order  the 
subject  to  live  on  mixed  diet,  con- 
suming the  most  of  that  kind  of  food 
which  lessens  the  uric  acid  in  the 
urine — vegetables.  Physiologic  ob- 
servations demonstrate  that  the  char- 
acter and  quantity  of  the  ingesta 
determine  the  character  and  quan- 
tity of  the  elimination.  If  the  ap- 
propriate food  is  so  valuable  in 
"visceral  drainage"  in  the  treatment 
of  the  typical  uric  acid  subject  the 
appropriate  food  selected  for  the  subjects  of  biliary  and  pancreatic,  faecal 
calculus,  will  be  relatively  as  useful.  The  foods  that  make  soluble  basic 
salts  with  secretions  should  be  selected.  Besides,  the  selection  of  appro- 
priate food  is  frequently  amply  sufficient  to  drain  the  intestinal  tract  to 
prevent  constipation.  It  is  true,  foods  alone  are  not  a  complete  substitute 
for  fluids,  but  vast  aid  in  visceral  drainage  may  be  accomplished  by  admin- 
istering food  containing  considerable  coarse  residual  indigestible  matter  so 
that  a  maximum  faecal  residue  will  stimulate  the  intestines,  especially  the 
colon,  to  continuous  vigorous  activity,  stimulating  to  a  maximum  action  of 


LYMPHATICS  OF  WALL  OF  ENTERON 
OF  CALF  (INJECTED) 

Fig.  166.  1,  First  upper  lymphatics  within 
the  intestinal  villi.  2,  next  lower  layer  inter- 
nal (sub  mucous)  lymphatic  network.  3,  next 
lower  layer  langlobate  glands  (10).  4,  ex- 
ternal layer  of  lymphatic  network  (observe 
the  valves  in  this  layer).  5,  circular  muscular 
layer.     6,  peritoneal  layer.     (Teichman.) 


TRACTUS   LYMPHATICUS   AND    LYMPH 


541 


the  four  grand  functions — sensation,  peristalsis,  absorption  and  secretion. 
For  twenty  years  I  have  treated  subjects  with  excess  of  uric  acid  in  the 
urine  by  administering  an  alkaline  laxative  in  fluid.  The  alkaline  tablet  is 
composed  of  cascara  sagrada  (3V  gr. ),  aloes  (\  gr.),  NaHC03  (1  gr.), 
KHCO3  (}  gr.),  MgS04  (2  grs.).  The  tablet  is  used  as  follows:  i  to  1 
tablet  (or  more,  as  required  to  move  the  bowels  once  daily)  is  placed  on  the 
tongue  before  meals  and  followed  by  8  ounces  of  water  (better  hot).  At  10 
a.  m.,  3  p.  m.,  and  bedtime  the  administration  is  repeated  and  followed  by  a 
glassful  of  fluid. 

In  the  combined  treatment  the  appropriate  dose  of  the  sodium  chloride 
and  alkaline  tablet  are  both  placed  on  the  tongue  together  immediately  fol- 
lowed by  the  8  ounces  of  fluid  six  times  daily.  This  method  of  treatment 
furnishes  alkaline  bases  (sodium  and  potassium  and  ammonium)  to  combine 


INJECTED   LYMPHATIC  VESSELS  OF  THE  TONGUE 

Fig.  1G7.     The  ample  transporting  lymph  apparatus  is  demonstrated  by  numerous  chan- 
nels with  ample  lumen.     (Teichman.) 


with  the  free  uric  acid  in  the  urine,  producing  perfectly  soluble  alkaline 
urates  and  materially  diminishing  free  uric  acid  in  the  urine.  Besides,  the 
sodium  chloride  and  alkaline  laxative  tablets  stimulate  the  sensation, peristalsis, 
absorption  and  secretion  of  the  intestinal  tract  (and  all  other  visceral  tracts) — 
aiding  evacuation.  I  have  termed  the  sodium  chloride  and  alkaline  laxative 
method  the  visceral  drainage  treatment.  The  alkaline  and  sodium  chloride 
tablets  take  the  place  of  the  so-called  mineral  waters.  Our  internes  have 
discovered  that  on  entering  the  hospital  the  patient's  urine  presents  numerous 
crystals  under  the  microscope.  However,  after  following  the  "visceral  drain- 
age treatment"  for  a  few  days,  crystals  can  scarcely  be  found  again.  The 
hope  of  removing  a  formed,  localized  ureteral  or  other  calculus  lies  in  secur- 
ing vigorous  ureteral  or  other  duct  peristalsis  with  a  powerful  ureteral  or 
other  duct  stream.  Transportation  of  ureteral  calculus  is  aided  by  system- 
atic massage  over  the  psoas  muscle  and  per  vaginam.     Subjects  afflicted  with 


542 


THE  ABDOMINAL   AND   PELVIC  BRAIN 


excess  of  the  uric  acid  (and  consequent  ureteral  calculus)  in  the  urine  or 
other  form  of  calculus  need  not  make  extended  sojourns  to  watering  places, 
nor  waste  their  time  at  mineral  springs  nor  tarry  to  drink  the  hissing  Sprudel 
or  odorous  sulphur,  for  they  can  be  treated  sucessf ully  in  a  cottage  or  palace 
by  " visceral  drainage."  The  treatment  of  a  uric  acid  or  other  calculus 
consists,  therefore,  in  the  regulation  of  food  and  water.  It  is  dietetic.  The 
control,  relief  and  prophylaxis  of  uric  acid  diathesis  or  tendency  to  other 
calculus  formation  is  a  lifelong  process.  When  the  uric  acid  or  other  cal- 
culus has  passed  spontaneously  the  patient  does  not  end  his  treatment,  but 
should  pursue  a  constant  systematic  method  of  drinking  ample  fluids  at  regu- 
lar intervals  and  consume  food  which  contains  bases  to  combine  with  free 
uric  acid  or  other  compounds  producing  soluble  urates  or  other  soluble 
compounds. 


LYMPHATICS   OF  THE  VERMIFORM  APPENDIX 

Fig.  168.  The  lymphatics  are  injected  and  present  valves.  There  are  two  conglobete 
glands.  This  lymph  apparatus  can  transport  infection  with  facility  on  account  of  its  num- 
erous channels  of  large  dimensions.     (Teichman.) 


I  continue  this  treatment  for  weeks,  months,  and  the  results  are  remark- 
ably successful.  The  urine  becomes  clarified  like  spring  water,  and  increased, 
in  quantity.  The  volume  and  rate  of  blood  flow  is  increased,  transporting 
increased  oxygen  to  tissue.  The  volume  and  rate  of  lymph  flow  is  increased, 
transporting  increased  nourishment  to  the  cell  and  increasing  cell  drainage, 
energizing  and  vitalizing  the  organism. 

The  tractus  intestinalis  becomes  freely  evacuated,  regularly  daily.  The 
blood  is  relieved  of  waste  laden  and  irritating  material.  The  tractus  cutis  eli- 
minates freely,  and  the  skin  becomes  normal.  The  appetite  increases.  The 
four  grand  common  visceral  functions — sensation,  peristalsis,  absorption  and 
secretion — are  acting  normally.  The  sewers  of  the  body  are  well  drained  and 
flushed.     The  sleep  becomes  improved.     The  feelings  become  hopeful. 


TRACTUS   LYMPHATICUS   AND    LYMPH 


543 


(c)  HABITAT  IN  VISCERAL  DRAINAGE. 

Habitat  includes  all  methods  of  living  from  the  sedentary  to  the  ath- 
letic, from  the  paralytic  to  the  traveler.  In  general  the  habitat  will  refer 
chiefly  to  the  tractusmuscularis  and  tractus  respiratorius.  Muscular  activity, 
vigorous  exercise,  enhances  two  grand  functions,  viz.,  tractus  vascularis  and 
tractus  glandularis. 

The  muscles  are  powerful  regulators  of  circulation  (blood  and  lymph) 
hence  their  stimulation  (exercise)  increases  the  tone  of  vessels,  magnifies 
blood  currents  to  viscera  which  consequently  multiplies  common  visceral 
function  (sensation,  peristalsis,  absorption  and  secretion),  ending  in  free 
visceral  drainage.  Muscular  activity 
increases  blood  volume,  universally 
improving  nutrition.  Maximum 
blood  volume  is  the  primary  base  of 
visceral  peristalsis.  The  most  typical 
popular  example  of  the  muscles  con- 
trolling the  blood  circulation  is  that 
of  the  uterus.  The  myometrium  like 
elastic  living  ligatures  controls  the 
uterine  blood  supply  (and  conse- 
quently its  functions),  (sensation, 
peristalsis,  absorption,  secretion, 
menstruation  and  gestation),  hence 
drainage  with  flaccid  muscles  drain 
glandular  secretion,  as  in  the  uterus, 
may  be  excessive  (leucorrhea). 

Exercise  is  an  essential  for 
health.  Muscles  exercise  a  domi- 
nating control  over  circulation  (blood 
and  lymph).  The  abdominal  mus- 
cles influence  the  caliber  of  the 
splanchnic  vessels.  They  exercise  an 
essential  influence  over  peristalsis, 
secretion,  absorption,  of  the  tractus 
intestinalis,  urinarius,  vascularis  and 
genitalis.  The  muscles  massage  the 
viscera,  enhancing  their  function  and 

the  rate  of  circulation  with  consequent  free  drainage.  In  the  uterus,  the 
most  typical  example  (especially  marked  during  parturition),  is  prominently 
demonstrated  how  the  myometrium  controls  the  blood  currents  like  elastic 
living  ligatures.  The  myometrial  bundles  by  continual  contraction  decreases 
the  dimension  and  blood  volume  of  the  uterus  at  a  moment's  notice  subse- 
quent to  parturition.  The  muscular  system  is  equally  and  continually 
influential,  at  all  other  time  as  it  is  parturition,  over  circulation  and  visceral 
function.      Regular  vigorous  habits  enhance  visceral  drainage. 

The  value  of  fresh  air  was  never  realized  so  effectively  and  practically  as 


LYMPH  VESSELS  OF  DOG'S  STOMACH 

Fig.  169.  a,  a,  superficial  layer  ;  b,  b,  deep 
layer,  anastomosing  lymphatics.  It  shows  a 
rich  transporting  tubular  apparatus.  (Teich- 
man.) 


544  THE   ABDOMINAL  AND  PELVIC  BRAIN 

at  present.  Fresh  cold  air  cures  pulmonary  and  other  tuberculoses.  The 
success  of  the  sanitorium  is  the  continued  use  of  fresh  (cold)  air.  The  sub- 
ject should  sleep  with  fresh  continuous  cold  air  passing  through  an  open 
window  space  of  3x3  feet.  Every  physician  should  advocate  the  continuous 
open  window,  day  and  night  for  living  and  sleeping  room.  It  appears  to  be 
demonstrated  that  cold  fresh  air  is  more  beneficial  than  warm  fresh  air.  It 
is  common  talk  among  people  that  one  winter  in  the  mountains  is  worth  two 
summers  for  the  consumptive.  Much  of  man's  disease  is  house  disease.  It  is 
lack  of  oxygen  and  exercise.  The  curative  and  beneficial  effect  of  cold  fresh 
air  continually,  day  and  night,  for  the  family  must  be  preached  in  season 
and  out  of  season  by  the  physician.  The  windows  should  be  open  all  night. 
Fresh  cold  air  is  one  of  the  best  therapeutic  agents  in  pathologic  physiology 
of  viscera.  It  stimulates  viscera  to  active  function  and  consequent  visceral 
drainage.  Observe  the  wonderful  results  of  systematic  deep  breathing, — 
chest  expansion.  It  utilizes  ample  oxygen  which  is  rapidly  transported  to 
the  tissue  by  the  tractus  vascularis.  If  one  observes  the  naked  body  in  rapid 
deep  breathing  it  will  be  observed  that  man's  respiratory  apparatus  extends 
from  his  nostrils  to  his  pelvic  floor,  i.  e.,  it  extends  to  the  territory  of  the 
spinal  (intercostal  and  lumbar)  nerves.  Hence,  by  stimulating  to  a  maximum 
the  functions  of  the  tractus  respiratorius  (sensation,  peristalsis,  absorption, 
secretion) — e.  g.,  by  systematic  deep  respiration — vast  benefits  result  to  the 
organism.  The  habitat  that  furnishes  opportunity  for  abundant  fresh  air,  like 
an  open  tent  on  the  plains  and  ample  muscular  exercise,  is  the  one  that  affords 
the  essential  chances  for  recovery  of  pathologic  physiology  viscera.  It  en- 
hances visceral  drainage.  Fresh  air  is  required  to  transport  a  continuous, 
ample  supply  of  oxygen  to  the  muscular  apparatus  to  maintain  its  normal 
tone,  its  contractions  and  relaxations. 

(d)  avocation  in  visceral  drainage. 

The  suitability  of  avocation  to  health  is  a  daily  observation.  The  pris- 
oners confined  in  a  cell,  the  clerk  confined  in  a  store,  stand  in  contrast  to 
the  subjects  living  in  the  field,  and  the  traveler  continually  exposed 
to  sun  and  wind.  The  sedentary  occupation  confining  the  laborer  affords 
insufficient  muscular  exercise  or  fresh  air  to  maintain  ample  visceral  drain- 
age. Visceral  drainage  is  required  for  health  as  nourishment.  Fresh  air 
aids  visceral  drainage  by  transporting  well  oxygenized  blood  to  the  viscera 
which  stimulates  the  four  common  visceral  functions.  The  avocation  should 
suit  the  laborer's  physique  that  the  four  common  visceral  functions  may  be 
normally  maintained. 

CONCLUSIONS  REGARDING  VISCERAL  DRAINAGE. 

Normal  visceral  drainage  is  the  key  to  health.  It  is  maintained  by  ap- 
propriate fluid,  food,  habitat,  avocation.  Visceral  drainage  depends  on  the 
normal  activity  of  the  four  common  visceral  functions  (sensation,  peristalsis, 
absorption,  secretion).  The  chief  factor  in  appropriate  visceral  drainage  is 
ample  fluid  administered  at  regular   intervals.     It  requires  five  pints  of  fluid 


TRACTUS    LYMPHATICUS   AND    LYMPH  545 

daily  to  compensate  for  the  visceral  elimination.  The  function  of  water  in 
the  organism  is: — 1,  elimination;  2,  solvent;  3,  transporter ;  4,  regulator  of 
the  temperature.  The  cells  of  the  body  (parenchymatous  and  connective 
tissue)  functionate  in  a  fluid  medium.  Life  can  persist  in  a  fluid  medium 
only.  Visceral  drainage  is  a  vast  factor  in  correcting  the  pathologic  physi- 
ology of  viscera  and  especially  the  tractus  lymphaticus.  Therapeutics  must 
be  rational,  for  nature  alone  can  cure.  Therapeutics  must  imitate  and  aid 
nature  in  restoring  function  by  natural  agents.  Practically  the  influence 
of  a  physician  is  limited  to  pathologic  physiology,  i.  e.,  the  zone  between 
normal  physiology  and  pathologic  anatomy.  The  physician's  chief  duty  is 
to  correct  function.  Visceral  drainage  produces  maximum  cell  nourishment 
and  maximum  cell  drainage,  hence  creates  maximum  energy  and  vitalizes  the 
organism.  Practically  ample  fluids  at  regular  intervals  is  recommended 
in  pathologic  physiology  of  the  viscera,  e.  g.,  in  obesity,  in  diabetes,  in  rheum- 
atism, in  fevers,  cholelithiasis,  nephrolithioses,  constipation.  Water  is  a 
vital  stimulant  to  the  life  of  a  cell. 


CHAPTER  XXXIX. 

SPLANCHNOPTOSIA  (ATONIA  GASTRICA). 

Factors.  1.  Deranged  respiration  (due  to  thoracic  splanchnoptosia). 
2.  Relaxed  Abdominal  wall.  3.  Altered  form  of  Abdominal  cavity  (Pendu- 
lous). 4.  Elongation  of  visceral  supports  (mesenteries).  5.  Gastro-duodenal 
Dilation  (due  to  compression  of  the  transverse  duodenal  segment  by  the 
superior  mesenteric  artery,  vein  and  nerve).  Splanchnoptosia  signifies 
abnormal  distalward  movement  (sinking  prolapse)  of  viscera.  Atonia 
gastrica  signifies  abdominal  relaxation  which  is  preceded  by  thoracic  relaxa- 
tion. Splanchnoptosia  is  included  in  the  diseases  of  the  vasomotor  nerve 
(sympathetic)  because  the  chief  and  final  effect  lies  in  its  domain.  It  is  true 
that  the  thoracic  (diaphragm)  and  abdominal  wall  (supplied  by  spinal  nerves) 
are  the  primary  factors  in  maintaining  and  fixing  the  thoracic  and  abdominal 
organs  in  their  normal  physiologic  position,  that  relaxation  of  the  thoracic 
(diaphragm)  and  abdominal  walls  are  the  primary  factors  in  splanchnoptosia, 
and  that  in  treatment  the  thoracic  (diaphragm)  and  abdominal  walls  (areas 
of  respiration)  are  the  primary  factors  for  consideration.  However,  the 
damaging  effects  on  the  life  of  the  patient  rests  on  the  seven  visceral  tracts 
(supplied  mainly  by  the  sympathetic  nerve)  viz: — (1)  Tractus  Respiratorius, 
(2)  Tractus  nervosus,  (3)  Tractus  vascularis,  (4)  Tractus  lymphaticus,  (5) 
Tractus  intestinalis,  (6)  Tractus  urinarius,  (7)  Tractus  Genitalis  (in  the  order 
enumerated). 

Pathological  Relations. 

The  object  of  this  essay  is  to  demonstrate  the  relations  of  splanchnopto- 
sia (atonia  gastrica) — to  pathologic  conditions,  as  deranged  innervation, 
circulation,  respiration,  secretion,  absorption,  muscularis.  Relaxation  of 
tissue — muscle,  elastic,  connective — means  elongation  of  the  same.  A 
triumvirate  of  conditions  in  splanchnoptosia  demand  skilled  consideration 
viz. :  Anatomy,  Physiology  and  Pathology  of  the  thoracic  and  abdominal 
viscera. 

In  the  first  place  we  wish  to  employ  scientific  nomenclature  only. 
Splanchnoptosia  indicates  the  ptosis  (falling)  of  the  thoracic  and  abdominal 
viscera  and  is  the  general  term  we  will  adopt.  It  is  constantly  accompanied 
by  relaxation  of  the  thoracic  (diaphragm)  and  abdominal  walls.  Gastroptosia 
signifies  abdominal  ptosis  (not  merely  of  the  stomach).  Atonia  Gastrica 
signifies  abdominal  relaxation  (and  should  for  accuracy)  displace  gastroptosia. 
However,  since  in  stomachoptosia  (ptosis  of  the  stomach  only)  there  are 
other  associated  visceral  ptoses,  the  terms  gastroptosia  and  atonia  gastric  are 
equivalent  terms  for  they  both  include  visceral  ptoses  and  relaxation  of  the 

546 


SPLASCIIXOPTOSIA 


547 


abdominal  walls.  Enteroptosia  is  ptosis  of  the  abdominal  viscera  in  general 
and  may  include  those  of  the  thoracic  cavity.  I  shall  reserve  for  the  term 
enteroptosia  the  signification  of  ptosis  of  the  enteron  (duodenum,  jejunum, 
and  ileum).  Coloptosia  means  ptosis  of  the  colon,  and  its  anatomic  seg- 
ments can  be  designated  by  an  adjective  as  coloptosia  transversa. 

Dr.  Achilles  Rose  of  New 
York  and  Dr.  Kossman  of 
Berlin  should  be  credited  for 
an  attempt  to  introduce 
scientific  nomenclature  in 
this  subject. 

Splanchnoptosia  though  a 
single  unit  is  a  general  dis- 
ease of  the  thoracic  and  ab- 
dominal viscera  accom- 
panied by  relaxation  of  the 
thoracic  and  abdominal  mus- 
cular walls.  In  short  splanch- 
noptosia prevails  wher- 
ever the  nerves  of  respira- 
tion innervate.  In  splanch- 
noptosia not  only  several 
viscera  are  simultaneously 
affected  but  also  the  thoracic 
and  abdominal  walls  are  re- 
laxed. From  an  erroneous 
and  limited  view  of  the 
founder  of  splanchnoptosia 
(Glenard)  and  the  accepta- 
tion of  the  error  by  numer- 
ous followers  the  idea  has 
prevailed  that  ptosis  of 
single  viscera  occur  and  to 
them  numerous  pathologic 
symptoms  have  been  at- 
tributed.      Hence   a  stately 

~.     ,Wrt       A   ,       ,        ,  n-  literature   has    arisen    from 

Fig.  170.       A   female    splanchnoptotic,    a    multipara,  . 

ventral  view  of  relaxed  abdominal  walls.  Observe  that  nephroptosia,  stomacnopto- 
the  relaxed  abdominal  walls  pass  sufficiently  distalward  gja  colop.tosia  (transversa), 
to  conceal  the  genitals  from  view.     Note  the  marked  dis-        '  .  „ 

talward  position  of  the  umbilicus.  There  is  a  depression  enteroptosia,  etc.,  etc.  Un 
at  the  epigastrium.  The  abdomen  is  flattened  (changed  ^js  error  0{  single  visceral 
in  form),  pendulous.  .     ,        ,  ,  ,    ,   ,. 

ptosis  has  been  founded  the 

irrational  surgery  of  so-called  visceral  pexies.      One  viscus  may  be  afflicted 

with  greater  degree  of  ptosis  than  another,  however,  splanchnoptosia  is  a 

general  process  affecting    the  thoracic  and    abdominal    walls,    the    visceral 

mesenteries  and  visceral  shelves. 


548 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


The  following  table  will  explain  itself: 

TABLE  OF  NOMENCLATURE  IN  SPLANCHNOPTOSIA  WITH  RESULTS. 


I.  Tractus 

Respiratorius 


II.  Tractus 
Nervosus 


III.  Tractus 

Lymphaticus 


IV.  Tractus 
Vascularis 


V.  Tractus 
Intestinalis 


VI.  Tractus 
Urinarius 


VII.  Tractus 
Genitalis 


} 


Ptosis  Pulmonalis 


Ueu 


ro-Ptosia 


Ptosis  Lymphaticus 


} 


Ptosis  Vascularis 


1.  Gastroptosia 

2.  Enteroptosia 

3.  Coloptosia 

4.  Hepato-Ptosia 

5.  Pancrea-Ptosia 
^6.  Lienoptosia 


1.  Adrenoptosia 

2.  Nephroptosia 

3.  Uretero-Ptosia 

4.  Vesico-Ptosia 


1.  Ovario-Ptosia 

2.  Oviducto-Ptosia 

3.  Metro-Ptosia 
,4.  Elytro-Ptosia 


n 


I 


'excessive  respiration 
.  deficient  respiration 
Result-!  disordered  respiration 

distalward  movement  of  the 
diaphragm 

rtrauma  (elongation,  pain) 
fmotion 
Result-1  altered  function    <^  secretion 
[^sensory 

^neurosis 

fflexion 
I  stenosis 
Result^  elongation 
j  dilatation 
(^neurosis 

'cardioptosia 
flexion 
stenosis 
elongation 
dilatation 
neurosis 

fflexion 
stenosis 
elongation 
dilatation 
Result*}  neurosis 


Result< 


Result^ 


Altered 


flexion 
stenosis 
dilatation 
neurosis 


Result< 


Altered 

'flexion 
stenosis 
neurosis 

Altered 


secretion 
absorption 
peristalsis 
sensation 


secretion 
absorption 
peristalsis 
sensation 


secretion 
absorption 
peristalsis 
sensation 


Historical, 

Though  Aberle,  Rollet,  Rayer,  and  Oppoltzer  presented  views  of 
splanchnoptosia,  it  is  probable  that  J.  B.  Morgangni  (Italian,  1682-1771)  was 
among  the  first  to  describe  splanchnoptosia  anatomically.  However,  it  is 
my  opinion  that  Rudolph  Virchow  (1821-1902),  my  honored  teacher,  deserves 
the  credit  of  calling  the  attention  of  physicians  to  splanchnoptosia.  He  did 
this  practically  in  1853  in  the  fifth  volume  of  his  archives  by  an  article 
entitled  "An  Historical  Critical  and  Exact  Consideration  of  the  Affections  of 
the  Abdominal  Cavity."     The  great  genius  of  Virchow  is  displayed  in  this 


SPLANCHNOPTOSIA 


549 


extensive  autopsic  investigation,  thirty-two  years  before  Glenard  stamped 
his  views  on  the  profession.  He  called  especial  attention  to  dislocation  of 
viscera  by  peritonitis  and  advocated  that  they  were  the  starting  points  of 
various  symptoms  of  dyspepsia  and  indigestion.     To  Kussmaul  we  owe  the 

first  definite  views  of  gastro- 
psia.  The  French  following 
Glenard  view  splanchnoptosia 
as  a  congenital  affection.  The 
Germans  are  opposed  to  this 
view  and  maintain  that  splanch- 
noptosia is  an  acquired  disease 
as  through  pregnancy,  peri- 
tonitis, method  of  dress,  avoca- 
tion, living  and  so  forth. 
Others  view  splanchnoptosia 
as  a  combined  effect,  congeni- 
tal predisposition  and  post 
natal  acquisition.  Among  some 
authors,  chiefly  German,  the 
view  is  entertained  that 
splanchnoptosia  is  a  reversion 
to  embryonic  condition  i.  e.,  the 
viscera  gradually  reverse  their 
embryonic  growth  and  develop- 
mental process. 

The  year  1885  was  an  event- 
ful one  in  the  pathology  and 
treatment  of  relaxed  abdominal 
walls,  and  consequent  splanch- 
noptosia. This  was  the  period 
in  which  Glenard's  labors  be- 
came known.  But  Glenard  was 
not  the  only  one  working  on 
the  subject  of  splanchnoptosis. 
Czerney  and  Keher,  of  Heidel- 
berg, were  presenting  cases  of 
visceral  ptosis  in  their  clinics  in 
1884  and  as  a  pupil  I  gained 
some  views  on  the  subject. 
However,  during  a  whole  year's 
study  in  Berlin  in  1885,  with 
distinguished  surgeons,  the 
subject  was  not  once  discussed.  Subsequently,  in  a  year's  course  of  study 
with  noted  German  specialists,  Professor  Schroder  showed  many  subjects  of 
splanchnoptosis.  Dr.  Landau,  who  wrote  "Wander  Niere"  (wandering  kid- 
ney) and  "Wander  Leber"  (wandering   liver),  gave  extensive    courses  and 


Fig.  171.  A  lateral  view  of  a  female  splanch- 
noptotic,  a  multipara,  showing  relaxed  abdominal 
walls  and  umbilicus  in  a  distalward  location.  The 
abdomen  is  pendulous.  An  attitude  of  lordosis  is 
assumed  for  balancing  support 


550 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


discussed  relaxed  abdominal  walls  and  consequent  splanchnoptosia,  in  an  in- 
teresting manner.  In  fact,  among  Germans  the  term  "Hangebauch"  (hang- 
ing belly)  has  been  common  for  twenty-five  years.  Dr.  August  Martin 
presented  instructive  views  on  the  subject  in  his  excellent  gynecologic 
course  to  physicians.     During  the   past  twenty  years  I   have   pursued    the 


Fig.  172.  A  female  splanchnoptotic  with  the  ventral  abdominal  walls  removed,  present- 
ing the  viscera  in  an  advanced  state  of  splanchnoptosia.  The  diaphragm  is  exposed  showing 
the  vena  cava  (v),  the  aorta  (a)  and  the  oesophagus  (ce)  projecting  through  it.  A  typical 
splanchnoptotic  relation  appears  with  the  liver  and  the  stomach  (st).  In  this  subject  the 
stomachis  practically  vertical.  The  right  and  transverse  colon  are  forced  in  the  greater 
pelvis  with  the  main  enteronic  loop.  The  flexura  coli  sinistra  (sp)  is  dragged  distalward. 
The  notable  phenomenon  in  this  subject  is  the  hypertrophy  and  distalward  movement  of  the 
right  hepatic  lobe — it  is  at  its  present  stage  a  typical  Riedel  lobe. 


SPLANCHN0PT0S1A  551 

study  of  splanchnology  among  hundreds  of  gynecologic  patients,  both  medi- 
cal and  surgical,  and  in  the  personal  abdominal  inspection  of  six  hundred 
adult  autopsies.  In  this  paper  I  will  present  essentials  of  the  knowledge 
gained  in  that  experience. 

General  Views  of  Splanchnoptosia  from  Embryology. 

The  abdominal  viscera  are  maintained  in  their  normal  physiologic  posi- 
tion by:  (a)  nerves  and  vessels;  (b)  peritoneum;  (c)  ligaments;  (d)  visceral 
pressure;  (e)  ligaments;  (f)  visceral  shelves;  (g)  abdominal  walls  (muscular 
and  osseous).  The  first  idea  of  importance  is  that  no  organ  is  absolutely  or 
immovably  fixed  but  that  each  viscus  is  endowed  with  a  certain  degree  of 
movement,  hence,  the  irrational  surgical  fixation  (pexies)  of  organs  is 
obvious.  The  mobility  of  organs  is  due  to  various  factors  as:  (a),  attitude 
(prone  or  erect);  (b),  respiration;  (c),  material  within  the  tractus  intestinalis 
(ingesta,  gas);  (d),  material  within  the  tractus  urinarius  (urine);  (e),  muscu- 
lar movement  of  viscera  (rhythm)  and  abdominal  wall;  (f),  gestation  (ma- 
terial within  the  tractus  genitalis).  Hence  the  abdomen  should  be  viewed  as 
occupied  with  viscera  capable  of  more  or  less  mobility — that  fixation  of 
abdominal  viscera  is  abnormal,  as  e.  g.,  peritoneal  bands  and  visceral 
pexies. 

The  embryology  of  the  abdominal  viscera  is  an  unending  source  of  inter- 
est. It  is  not  a  surpiise  that  after  noting  the  development  and  axial  rotation 
of  the  tractus  intestinalis  the  view  should  be  entertained  that  splanchnoptosia 
is  a  reversion  of  development  and  axial  rotation  of  the  digestive  tube,  i.  e., 
that  the  tractus  intestinalis  (and  its  appendages)  has  retraced  its  lines  of 
development.  In  the  early  embryo  the  tractus  intestinalis  is  a  straight  tube 
extending  from  mouth  to  anus  in  the  middle  line  of  the  body  (with  the  liver, 
spleen  and  pancreas).  Gradually  with  the  progress  of  months  the  coecum 
passes  from  left  to  right  across  the  ventral  surface  of  the  enteron  (duodenum) 
and  ends  at  birth  in  the  region  of  the  right  kidney. 

The  liver  gradually  passes  from  the  middle  line  to  the  right  proximal 
quadrant  of  the  abdomen  ending  in  the  adult  in  the  right  concavity  of  the 
diaphragm.  This  process  of  hepatic  development  is  not  complete  at  birth 
for  the  large  (pot)  belly  of  the  child  is  due  to  a  large  liver.  In  typical 
splanchnoptosia  the  position  of  the  abdominal  organs  stimulate  those  of  the 
embryo  and  infant.  Seeking  a  clue  for  treatment  from  embryologic  phenom- 
ena it  would  be  that  splanchnoptosia  is  a  general  visceral  disease  and  that 
rational  treatment  should  be  applied  to  the  abdominal  walls — not  to  single 
viscera  as  visceral  pexies. 

Clinical  Aspects. 

From  a  clinical  view  certain  organs  may  appear  of  more  significance  in 
splanchnoptosia  than  others.  For  example  the  general  surgeon  who  does 
not  investigate  the  subject  of  splanchnoptosia  centers  his  observations  in  idol 
worship  on  the  liver,  kidney,  uterus  or  stomach  and  with  his  cranium  com- 
pletely occupied  with  visceral  pexies  (heathen  gods  in  physiology)  initiates 


552  THE  ABDOMINAL  AND  PELVIC  BRAIN 

his  campaign  of  pexies  or  visceral  fixation  by  suturing  one  of  those  organs  to 
the  abdominal  wall.  What  has  he  accomplished?  He  has  produced  one 
lesion  (visceral  fixation)  in  attempting  to  improve  another  (supposed  excess- 
ive visceral  mobility).  Generally  the  worst  is  visceral  fixation  because  the 
fixation  is  unphysiologic,  irrational  and  affects  but  a  detached  part,  a  seg- 
ment of  the  general  splanchnoptosia.  The  therapeusis  should  be  applied  to 
the  abdominal  wall. 

The  embryologic  view  demonstrates  that  the  seven  visceral  tracts  (respi- 
ratorius,  intestinalis,  circularis,  lymphaticus,  nervosus,  urinarius  and  geni- 
talis) are  practically  alike  affected — splanchnoptosia  is  a  unit  though  a  general 
disease.  However,  the  symptoms  of  splanchnoptosia  of  some  visceral  tracts 
are  not  so  manifest  as  that  of  others  e.  g.,  the  tractus  nervosus  is  practically 
manifest  as  that  of  the  urinarious  and  intestinalis.  Embryology  suggests 
that  viscera  of  late  development  and  distant  fixation  from  the  radix  mesen- 
terica  (coeliac  and  superior  mesenteric  arteries)  are  prominent  in  splanch- 
noptosia as  the  liver,  stomach,  colon,  genitals,  kidney.  They  are  distantly 
removed  from  the  solid  anchorage  of  the  radix  mesenterica  and  their  solid 
fixation  is  hence  more  limited  by  peritoneal  bands  to  the  abdominal  wail. 

For  example  the  liver  is  practically  fixed  to  the  diaphragm  only.  Its 
fixation  to  the  radix  mesenterica  is  limited  by  the  anchorage  it  may  obtain 
from  the  arteria  hepatica  ensheathed  with  its  fibrous  tissue  from  the  aorta 
and  its  encasement  of  plexiform  nerve  network  from  the  abdominal  brain. 
It  must  be  admitted,  however,  that  the  late  mesenterial  development  or 
expanding  of  the  base  of  mesenteries,  the  increased  areas  of  peritoneal 
adhesions  (non-pathologic)  to  the  dorsal  wall  as  occurs  in  the  liver,  colon, 
stomach  enteron  serves  as  valuable  fixation  for  the  viscera.  These  acquired 
basal  mesenterial  expansions  produce  compact  solidarity  of  organs  re-enforc- 
ing the  supporting  strength  of  the  radix  mesenterica  (vascular). 

GENERAL   PATHOGENESIS    OF   SPLANCHNOPTOSIA. 

The  method  of  origin  (aetiology)  and  development  of  splanchnoptosia 
is  explained  by  different  authors  through  different  views.  The  divergent 
views  entertained  depend  on  the  assumed  beginning  base — whether  splanch- 
noptosia be  due  to  (a)  congenital  predisposition;  (b)  acquired  defects  from 
life's  opposing  forces;  (c)  reversion  to  embryologic  conditions  or  (d)  a  com- 
bination of  the  three  preceding  factors. 

First,  a  congenital  predisposition  suggests  a  characteristic  body  form  or 
congenital  weakness  or  fragility  of  tissue  which  predisposes  the  individual  in 
the  conflict  of  life's  resisting  forces  to  splanchnoptosia. 

Second,  acquired  defects  producing  splanchnoptosia,  attempts  to  explain 
rationally  the  varied  factors  as  rapidly  repeated  gestations,  sudden  loss  of 
fatty  tissues,  pathologic  conditions  of  the  abdominal  wall,  body  form,  the 
influence  of  visceral  motion  in  respiration,  the  evil  effect  of  living  and  dress- 
ing (constricting  bands),  as  well  as  various  industries  and  traumata. 

Third,  reversion  to  embryonic  conditions  would  practically  be  a  con- 
stitutional predisposition  and  hence  belong  to  congenital  predisposition. 


SPLANCHNOPTOSIA  553 

Fourth,  the  view  which  includes  the  combined  factors  of  each  theory 
(congenital  or  acquired  defects)  of  splanchnoptosia  is  the  more  rational, 
because  the  disease  is  generally  prevalent  among  all  nations. 

Anatomy  and  Physiology. 

In  the  pathogenesis  of  splanchnoptosia  two  factors  must  be  carefully 
investigated,  viz. :  Anatomy  and  physiology.  The  anatomy  must  not  only 
include  the  elements — connective  tissue,  muscle,  elastic  fiber  and  bone — but 
bodily  form,  attitude,  avocation,  modes  of  life.  The  physiology  must 
include  all  the  consideration  of  visceral  functions — respiration,  gestation, 
circulation,  absorjtfion,  secretion  and  rhythm. 

Glenard  a  physician  at  Lyons,  France,  who  practiced  at  Vichy  observed 
that  splanchnoptosia  was  closely  related  to  neurasthenia  and  nervous  dyspep- 
sia. Glenard  observed  three  groups  of  symptoms  viz:  (1)  (atonia  gastrica) 
abdominal  relaxation  or  lack  of  tone  in  the  abdominal  wall  which  presented: 
(a)  deformity  of  the  abdominal  wall;  (b)  flabbiness,  relaxation  of  the  abdom- 
inal wall;  (c)  ease  with  which  the  hypochondrium  may  be  compressed.  (2) 
Splanchnoptosia  presented:  (a)  (gastroptosia)  splashing  sounds  in  the 
stomach;  (b)  epigastric  pulsation;  (c)  nephroptosia;  (d)  coloptosia  transver- 
sum.  (3)  Enteroptosia  presented  three  signs:  (a)  a  palpable  contracted  band 
of  the  transverse  colon ;  (Glenard's  corde  transverse  colique)  (b)  the  coecum ; 
(c)  the  sigmoid. 

Glenard  found  at  Vichy  resort  148  cases  of  splanchnoptosia  in  1,310 
subjects — llc/c  He  practiced  among  a  neurotic  class  of  subjects.  Glenard 
believed  that  the  starting  point  of  splanchnoptosia  is  the  sinking  of  the 
flexura  coli  hepatica  due  to  relaxation  of  the  ligamentum  flexura  hepatica. 
He  considered  that  ptosis  of  single  viscera  could  occur  in  four  conditions,  viz. : 
(a)  neurosis;  (b)  hepatic  disease;  (c)  dyspepsia;  (d)  general  or  conditional 
illness.  The  three  main  symptoms  of  splanchnoptosia  according  to  Glenard 
are  colic,  stenosis,  nephroptosia  and  hepatic  deformity.  Glenard  studied  40 
splanchnoptotic  autopsies  and  concluded  that  when  the  suspensory  ligaments 
of  the  stomach  and  intestines  are  relaxed  accompanied  by  the  distalward 
movements  of  these  viscera,  stenosis  will  occur,  and  the  coecum  alone  will 
maintain  its  normal  form  as  it  has  no  suspensory  ligament.  Glenard's  belt 
test  of  splanchnoptosia  consists  in  the  physician  standing  behind  the  patient, 
elevating  the  abdomen  with  the  handsr  and  if  it  affords  relief  the  diagnosis  is 
confirmed.  The  characteristic  symptoms  are:  sensations  of  weakness, 
abdominal  discomfort,  constipation. 

Space  forbids  further  views  from  Dr.  Frantz  Glenard,  the  founder  of 
splanchnoptosia  whose  excellent  book  of  875  pages  lies  before  me.  It  was 
published  in  1899  and  entitled  the  author  to  the  pathologic  eponym 
'"Glenard's  disease."  The  title  of  the  book  is  "Des  Ptoses  viscerales  Diag- 
nostic et  nosographie  (enteroptosie — Hepatisme)."  It  is  a  monument  of 
industry  which  will  be  admired  for  all  time. 

Through  all  the  pathogenesis  of  splanchnoptosia  neurosis  is  a  constant 
accompaniment,  inseparably  connected.     In  1896  Stiller  published  an  article 


THE   ABD0M1XAL   AND   PELVIC   BRAIX 


in  which  he  claims  that  there  is  a  neurasthenic  stigma  (stigma  neurastheni- 
cum),  the  floating  tenth  rib  (costa  decima  fluctuens).  Stiller  believes  that 
splanchnoptosia    rests  on    embryologic  defect    (vitium  primas  formationis). 

This  should  be  known  by  the 
pathologic  eponym  St  fil- 
er's costal  stigma."  This 
view  is  supported  by  rinding 
nephroptosia  in  children. 
Splanchnoptosia  subsequent 
to  parturition  (puerperium) 
should  be  designated  by  the 
pathologic  eponym  "Lan- 
dau's splanchnoptosia." 

Splanchnoptosia  accom- 
panying chlorosis  should  be 
designated  by  the  pathologic 
eponym  "Meinert's  splanch- 
noptosia."  Dr.  Einhorn  be- 
lieves that  constricting  bands 
(corset)  play  a  large  role  in 
the  pathogenesis  of  splanch- 
noptosis. 

Keith' s  TJieory. 

In  the  pathogenic  theories 
of  splanchnoptosia  the  latest 
most  elaborate  and  compre- 
hensive is  that  of  Arthur 
Keith,  in  the  Hunterian  lec- 
tures of  1903,  published  in 
the  London  Lancet,  March 
7,  and  14,  1903.  Mr.  Keith 
claims  in  these  most  excel- 
lent and  well  studied  lectures 
that  splanchnoptosia  is  the 
result  of  a  vitiated  method 
of  respiration.  Keith's  in- 
vestigations o  f  splanch- 
noptosia were  conducted  on 
an  anatomic  base  rather  than 
a  clinical  one  and  include 
vast  labors  based  on  the  solid 
ground  of  nature.  I  wish 
here  to  acknowledge  my  in- 
debtedness to  Mr.  Arthur 
Keith. 


Fig.  173.  Represents  the  abdominal  and  thoracic 
organs  separated  by  the  diaphragm.  The  pillars  or 
crura  of  the  diaphragm  (AC  and  A  C)  are  marked, 
demonstrating  that  inspiration  drags  (forces)  the  thor- 
acic organs  distalvvard.  Observe  that  the  pericardium 
is  solidly  and  firmly  fixed  to  the  diaphragm,  hence  in 
inspiration,  when  the  diaphragm  moves  distalward,  the 
heart,  lungs,  and  great  thoracic  vessels  must  accompany 
it 


SPLANCHNOPTOSIA  555 

Additional  lure  tors  in   Etiology. 

1.  Intra  abdominal  pressure. 

Factors  which  increase  intra-abdominal  pressure:  1,  Gestation.  2,  Food. 
3,  Fluid.  4,  Meteorism.  5,  Adispose  deposits.  6,  Ascites.  7,  Tumors. 
8,  Pleurisy.  9,  Feces.  10,  Urine.  11,  Gastro-duodenal  dilatation.  12, 
Coughing,     13,  Contracted  pelvis.      14,  Blood  and  lymph  volume. 

2.  Relaxed  abdominal  walls. 

This  consists  in  elongation  and  separation  of  fascial  and  muscular  fibres 
of  the  anterior  abdominal  walls,  the  thoracic  and  pelvic  diaphragm. 

3.  Compression  of  the  transverse  segment  of  the  duodenum  by  the 
superior  mesenteric  artery,  vein  and  nerve. 

4:   Congenital  defects  in  the  nervous,  muscular  and  visceral  systems. 

5.  Defective  food  and  excessive  labor. 

6.  Lordosis  or  anterior  curvature  of  the  vertebral  column  enhances 
splanchnoptosia. 

7.  With  the  progress  of  relaxed  abdominal  walls  there  is  a  dispropor- 
tionate or  abnormal  relation  established  between  the  nervous  and  muscular 
systems,  and  coordination  is  defective  and  hence  nourishment  and  function 
are  also  defective.  The  trauma  to  the  sympathetic  nervous  system  produces 
excessive,  deficient  or  disproportionate  secretions  and  peristalsis  in  the  vis- 
cera, hence  nourishment  is  again  defective.  With  the  advance  of  splanch- 
noptosia the  blood  and  lymph  vessels  become  stenosed,  their  mechanism 
disturbed,  producing  irregular  circulation  and  hence  nourishment  is  again 
defective. 

Splanchnoptosia  is  a  kind  of  neurosis.  It  is  devitalizing  of  the  sympa- 
thetic system  in  which  vitality  of  the  neuro-vascular  visceral  pedicle  is 
impaired,  it  becoming  elongated,  stretched.  Perhaps  the  elastic  tissue  is 
degenerated. 

Notwithstanding  the  manifold  theories  and  dreams  of  respected  authors 
and  the  easily  recognized  original  work  of  industrious  investigators  in 
splanchnoptosia  I  am  still  convinced  that  one  of  the  great  factors  of  splanch- 
noptosis is  the  waist  or  constricting  band,  not  merely  the  corset,  for  a  corset 
may  be  worn  so  loose  that  it  practically  does  no  damage.  During  the  past 
15  years  Dr.  Lucy  Waite  and  the  author  have  dissected  over  35  female  bodies 
for  practical  topographical  and  applied  anatomy  of  the  abdominal  and  pelvic 
viscera.  We  opened  the  cadaver  and  then  with  the  two  hands  as  a  corset 
band  or  any  form  of  waist  band  the  body  was  compressed  and  the  result  on 
the  abdominal  viscera  noted.  What  will  happen  in  tightening  the  waist 
band?  The  answer  is  clearly  evident  in  watching  the  progress  of  constricting 
the  band.  First  the  right  more  mobile  kidney  moves  medianward  and  ven- 
tralward,  compressing  the  junction  of  the  descending  and  transverse  duodenal 
segments,  ending  in  a  position  almost  in  the  middle  of  the  abdomen.  The 
kidney  suffers  the  most  movement  dislocation  of  any  abdominal  organ.  The 
liver  is  compressed  as  is  shown  in  autopsies  in  the  corset  liver,  the  gall- 
bladder projects  ventralward,  allowing  stagnation  of  bile  and  subsequent 
formation  of  hepatic  calculi.     The  daily  effect  of  the  waist  or  constricting 


THE  ABDOMINAL  AXD  PELVIC  BRA IX 

band  is  diminutive,  but  continued  from  week  to  week,  month  to  month,  and 
year  to  year,  its  end  results  are  enormous  in  changing  and  damaging  structure 
and  function.  It  constricts  the  right  colon,  compromising  cecal  evacuation, 
the  canalization  of  the  ureter,  renal  and  ovarian  veins  and  inferior  vena  cava. 
The  nephroptosia  elongates  the  renal  vessels  especially,  the  artery  which  is 
sheathed  in  a  network  of  ganglia  not  only  traumatizing  them,  but,  by  tugging 
and  dragging  on  the  abdominal  brain,  the  trauma  produces  the  stigmata  of 
hysteria  and  other  neuroses. 

Peritoneal  and  Omental  Adhesions. 

I  wish  here  to  direct  the  attention  of  the  practitioner  to  a  fertile  field  in 
the  etiology  of  splanchnoptosia  which  in  short  is  peritoneal  and  omental 
adhesions.  I  have  published  numerous  articles  during  the  past  decade  advo- 
cating the  evil  influence  of  peritoneal  adhesions  on  the  abdominal  viscera.  I 
am  gratified  to  observe  that  several  physicians  as  Robert  T.  Morris  and  sev- 
eral others  are  realizing  the  value  of  these  views.  In  hundreds  of  autopsies  I 
have  noted  the  structures  of  the  genitals,  appendix,  gall-bladder  and  sigmoid 
apparently  ruined  by  contracting  peritoneal  adhesions  distorting  the  viscera 
into  a  shapeless  mass. 

I  have  explained  for  years  how  these  peritoneal  adhesions  induced  by 
muscular  trauma,  created  distorted  physiology,  ending  in  appendicitis, 
cholecystitis,  sigmoiditis  and  salpingitis.  Peritoneal  adhesions  fix  the  viscera 
in  a  single  mass  so  that  the  several  viscera  cannot  glide  on  each  other.  The 
solid  visceral  mass  acts  like  a  solid  piston  in  the  abdomen  forcing  the  viscera 
distalward.  The  omentum  is  frequently  found  extensively  adherent  to  the 
pelvic  viscera  which  drags  the  viscera  in  the  proximal  abdominal  distalward 
at  every  respiration.  Peritoneal  adhesions  are  extensively  vicious  factors  in 
compromising  visceral  anatomy  and  physiology  and  abetting  remarkably 
splanchnoptosia  and  other  diseases. 

General  Views. 

If  single  viscera  become  markedly  splanchnoptotic,  prolapsed  by  acci- 
dent, trauma,  the  general  painful  neurotic  symptoms  of  splanchnoptosia  are 
markedly  absent  The  existence  and  results  of  splanchnoptosia  are  not  fully 
explained.  The  difficulty  has  its  seat:  (a),  in  the  determining  of  the  exact 
or  normal  position  of  viscera;  (b),  the  exact  forces  which  establish  an  organ 
in  its  position;  (c),  the  views  of  the  cause  or  origins  of  splanchnoptosia  are 
so  various  as  to  obscure  the  picture;  (d),  the  symptoms  are  so  complex  that 
splanchnoptosia  appears  like  a  conglomerate  disease.  The  confusion  is  due 
to  the  multiple  points  from  which  the  disease  has  been  established.  The 
history  of  splanchnoptosia  is  that  of  displacement  of  single  organs. 

Glenard,  though  comprehending  a  limited  field,  combined  them  into  a 
single  disease,  a  unit  which  should  now  be  termed  splanchnoptosia  because 
it  involves  the  thoracic  and  abdominal  viscera  (as  well  as  their  respective 
enclosing  walls).  Splanchnoptosia  is  a  disproportion,  a  disturbed  relation 
between    cavity    lumen  (chest,   abdomen)  and    contents  (viscera)  not    only 


SPLANCHNOPTOSIA  557 

anatomically  but  physiologically,  that  is  the  functionating  organs  are  working 
in  a  distorted,  dislocated  position  hence  experiencing  a  change  of  form  and 
function. 

The  thoracic  and  abdominal  cavities  should  be  viewed  as  one  general 
lumen,  simply  divided  by  the  diaphragm.  The  vertebral  column  may  be 
viewed  as  a  mast  maintaining  its  erectness  by  means  of  the  erector  spinse 
muscles.  The  ribs,  sail  arms,  receive  support  from  the  fixed  mastoid  process 
through  the  sterno-cleido  mastoid  muscle.  The  viscera  are  anchored,  fixed 
to  the  dorsal  wall — the  great  mast.  The  solid,  visceral  contents  are  confined, 
maintained  to  the  mast  by  the  circular,  fibro-elastic  muscular  band — the 
thoracico-abdominal  walls. 

The  physiology  of  viscera  must  be  credited  with  the  greatest  role  in 
splanchnoptosia  for  during  their  maximum  functions  the  weakest  and  most 
defective  anatomy  begins  to  yield — especially  in  the  diaphragm  (in  inspira- 
tion), in  the  abdominal  walls  (in  gestation,  ingesta,  gas,  defecation) ;  in  the 
circulation,  variation  of  the  volume  of  arterial,  venous  and  lymphatic 
fluids.  Intra-abdominal  pressure  is  the  contraction  of  the  circular  fibro- 
elastic  muscular  abdominal  wall  plus  atmospheric  pressure. 

Mechanism  of  Splanchnoptosia. 

We  know  that  the  extra-abdominal  pressure  is  greater  than  the  intra- 
abdominal pressure,  for,  on  peritoneal  section  the  atmosphere  rushes  in  with 
an  audible  sound.  This  view  would  oblige  the  visceral  supports  (mesenteries 
and  ligaments)  to  assume  the  office  of  not  only  anchorage  but  that  of  fixation 
(and  support).  Viscera  are  essentially  supported  by  underlying  ones  (visceral 
shelves)  like  bricks  in  a  wall.  Schwerdt  estimates  that  the  viscera  mesen- 
teries or  ligaments  support  about  one-eighth  of  the  organ  weight.  The 
fixation  of  the  viscera  to  the  (dorsal)  abdominal  wall  and  their  share  in  the 
visceral  support  might  be  compared  to  a  boat  at  anchorage.  The  boat  rests 
on  the  water,  which  represents  the  compact  supporting  visceral  shelves  (like 
bricks  in  a  wall).  The  anchor  cable  (mesenteries,  ligaments)  merely  decides 
the  limit  or  space  range  of  the  boat  (in  fact  seldom  becoming  tensionized). 
The  banks  of  the  water  represent  the  abdominal  wall. 

The  principal  support  of  the  viscera  are:  (a),  the  compact  underlying 
visceral  shelves;  (b),  the  abdominal  wall;  (c),  the  visceral  supports  (mesen- 
teries, ligaments)  perhaps  suspending  one-eighth  of  the  weight  of  the  viscera. 
By  placing  a  body  erect  and  removing  the  ventral  wall  the  viscera  pass  dis- 
talward,  prolapse,  sink,  placing  the  visceral  mesenteries  and  ligaments  on 
tension.  The  visceral  mesenteries  or  ligaments  might  be  compared  to  a 
string  attaching  a  specimen  in  a  fluid  filled  jar,  to  the  cork.  The  string 
support  is  limited,  but  without  it  the  specimen  would  sink  or  rest  on  the 
floor  of  the  jar. 

The  abdominal  viscera  are  located  more  distalward  while  in  the  erect 
attitude  (1  inch)  than  the  prone  position.  The  more  solid  organs  as  liver, 
kidneys,  uterus  and  foreign  material  occupied  segments  of  the  tractus  intes- 
tinalis  pass   distalward  with  more  facility   while  organs  containing  gas  pass 


558 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


Fig.  174.  This  illustration  demonstrates  the  dorsal  fixation  and  location  of  the  mesen- 
teries of  the  abdominal  viscera.  The  dotted  spaces  surrounded  by  black  lines  are  the  bases 
or  areas  of  mesenteric  insertion.  1,  Ligamentum  triangulum  sinistrum ;  2,  ligamentum 
suspensorium  (teres)  hepatis;  3  and  5,  vena  cava  (distal);  4,  arteria  phrenica  dextra;  16, 
omentum  gastro-hepaticum  ;  15,  ligamentum  gastro-phreneum  ;  8,  arteria  coeliaca;  7,  arteria 
gastrica;  12,  arteria  linealis;  13,  arteria  hepatica;  14,  spleen;  17,  mesocolon  transversum ; 


SPLANCHNOPTOSIA  55'J 

proximalward  with  more  facility.  Abdominal  organs  are  limited  in  motion 
through  the  mesenteries,  ligaments  and  adjacent  organs.  The  abdominal 
wall  exercises  an  opposition  to  the  static  pressure  of  viscera.  With  increased 
contents  (ingesta,  fluids,  gestation)  the  ventral  abdominal  wall  yields.  If 
a  body  be  hung  by  the  head  and  the  abdomen  incised  the  viscera  will  prolapse. 
In  the  resting  upright  attitude  the  abdominal  wall  offers  but  passive  pressure 
opposition  to  the  viscera. 

The  reason  for  the  slow  progress  in  the  knowledge  of  splanchnoptosia 
among  medical  men  is:  (a),  the  autopsic  reports,  for  the  past  years,  have 
been  of  limited  practical  value  as  regards  splanchnoptosia.  The  reason  of 
this  fact  is  that  when  the  subject  is  in  the  prone  but  especially  the  dorsal 
position  the  organs  assume  chiefly  their  normal  physiologic  location.  The 
pathologist  does  not  appear  to  have  anything  to  report;  (b),  the  clinician 
seldom  witnesses  an  autopsy  on  a  previously  diagnosed  splanchnoptotic. 
Hence  the  autopsist  and  clinician  have  practically  opposed  each  other — pos- 
sessed no  views  in  common — did  not  agree  and  also  seldom  met  at  an  autopsy. 
The  pathologist  in  the  morgue  returned  no  evidence  to  aid  the  clinician  on 
the  living.  In  the  symptomatology  heretofore  a  tendency  has  existed  to 
attribute  excessive  symptoms  to  single  splanchnoptotic  organs,  especially  the 
genitals,  kidneys,  stomach  and  liver,  and  deficient  symptoms  to  other  organs 
as  the  colon,  enteron,  vascular  system  and  nervous  system.  Splanchnoptosia 
is  a  unit — a  general  disease.  Also  excessive  symptoms  have  been  attributed 
to  single  organs  in  order  to  prepare  the  road  for  the  irrational  pexy. 

ANATOMY  AND  PHYSIOLOGY  OF  SPLANCHNOPTOSIA.       ABDOMINAL  WALLS. 

The  abdominal  walls  consist  of  oblique,  perpendicular  and  transverse 
muscular  layers  woven  in  a  powerful  fascial  band. 

All  abdominal  muscles  are  fixed  on  bony  parts,  as  the  costal,  iliac  and 
pubic  crests,  as  well  as  the  vertebral  column,  while  the  diaphragm  is  inserted 
into  the  ribs  and  vertebral  column  with  its  vault  fixed  by  the  pericardium. 
The  abdominal  wall  is  covered  externally  by  skin  and  internally  by  peri- 
toneum— both  powerful  and  elastic  membranes.  Certain  weak,  yielding 
muscular  and  fascial  lines  exist  in  the  abdominal  walls,  viz. : 

1.  Musculi  recti  abdominales  arise  from  the  pubic  crest  and  become 
inserted  into  the  ribs  and  os  sternum.  The  two  recti  muscles  which  lie  parallel 
to  each  other  are  the  ones  which  preserve  the  delicate  visceral  poise.  Slight 
extra  intra-abdominal  pressure  produces  diastasis  of  the  muscles.  In  splanch- 
noptosis, the  recti  show  (a)  diastasis,  (b)  elongation,  and  (c)  separation  of 
the  fibres,  (d)  extensive  thinning  and  flattening,  and  (e)  atrophy. 

10,  ligamentum  casto-coelicum ;  11,  kidney;  a,  omentum  gastro-splenicum ;  18,  shows 
dot  between  blades  of  omentum  majus ;  19,  adfenal  bodies ;  20,  foramen  winslowi ;  22, 
arteria  mesenterica  superior;  23,  arteria  renalis  dextra;  24,  mesocolon  sinistrum.  (Inser- 
tion line  of  its  two  blades.)  25,  duodenum  transversum  (covered  by  peritoneum) ;  26, 
mesocolon  dextrum.  (Insertion  line  of  its  right  and  left  blade.)  27,  ureter  (shimmering 
through  the  peritoneum)  ;  28,  aorta ;  29,  mesenteron ;  30,  arteria  mesenterica  inferior ;  31, 
arteria  colica  dextra;  32.  arteria  iliaca  communis;  33,  arteria  iliaca  externa;  34,  arteria 
iliaca  interna ;  35,  mesosigmoid.  (Double  blades.)  36,  uterus  ;  37,  urinaria  vescicae  ;  38, 
ligamentum  rotundum  uteri ;  39,  ovarium  ;  40,  oviductum  (sinistrum). 


560 


THE  ABDOMLXAL  A\D  PELVIC  BRAIN 


2.  The  fascial  lines  which  yield  in  splanchnoptosia  are  (a)  the  linea 
alba,  which  I  have  noted  three  inches  wide,  the  fascial  fibres  are  elongated 
and  separated,  making  the  abdominal  wall  very  thin  and  lax  in  the  median 
line,  (b)  the  lineae  semilunaries  which  also  become  quite  thin  and  lax,  the 
fascial  fibres  elongate  and  separate,  (c)  the  fibres  of  the  linea  transversa, 
inscriptiones  tendinat  or  the  abdominal  ribs,  which  elongate  and  separate. 
The  physiologic  action  of  the  abdominal  wall  is  a  combined  one,  as  the 

varied  direction  of  its 
muscular  fibres  indicate. 
We  may  indicate  its 
physiologic  action  in  cer- 
tain directions.  1.  The 
abdominal  wall  acts  as  a 
circular  band,  to  fix  and 
support  the  abdominal 
viscera  as  the  neurovas- 
cular visceral  pedicles  are 
not  intended  for  primary 
mechanical  visceral  sup- 
port. 2.  The  abdominal 
wall  is  a  highly  elastic 
apparatus.  It  distends  and 
contracts  fitting  the  ab- 
dominal contents.  The 
skin  and  peritoneum  are 
exceedingly  elastic.  Ob- 
serve how  the  skin  and 
peritoneum  will  return 
without  a  fold  to  the  nor- 
mal state  after  distention 
from  gestation,  ascites  or 
tumors,  etc.  3.  The  physi- 
cal function  of  the  ab- 
st^Z  dominal  wall  is  aided  by 
its  capacity  of  contraction 
and  of  extension  in  res- 
piration, defecation,  uri- 
nation, expulsion  of  uter- 
ine contents;  in  laughing 
and  coughing.  In  short  it  is  the  function  of  the  abdominal  wall  to  contract 
and  dilate  during  the  volume  changes  of  the  abdominal  contents,  as  well  as 
the  volume  changes  in  the  thorax.  4.  The  physiological  function  of  the 
abdominal  wall  is  to  maintain  a  vigilant  guard,  a  vigorous  but  delicate 
elastic  regulation  of  abdominal  visceral  contents.  The  elastic  spanning  of 
the  abdominal  walls  maintains  a  delicate  visceral  poise. 


Fig.  175.     Represents  the  separation  and  elongation  of 
the  recti  abdominales  in  splanchnoptosia. 


SPLAXCHXOPTOSIA 


561 


Etiology  of  Relaxation. 

Relaxed  abdominal  walls  arise  in  various  forms  in  different  subjects. 
Not  all  thin  abdominal  walls  are  relaxed,  neither  are  all  relaxed  abdominal 
walls  thin.  The  elements,  the  fascial,  elastic  and  muscular  fibres  must  be 
separated  and  elongated  to  constitute  relaxed  abdominal  walls,  which  are 
best  observed  in  the  erect  attitude.     The  causes  of  relaxed  abdominal  walls 


Fig.  176.  The  diaphragm.  (Ventro-distal  view.)  This  illustration  presents 
the  central  tendon  of  the  diaphragm  with  its  important  long  right  (RC)  and 
short  left  (LC)  crus.  The  right  diaphragmatic  crus  extends  to  the  (IV) 
lumbar  vertebra.  ■  The  crura  of  the  diaphragm  have  a  fixed  immobile  spinal 
insertion  and  forcible  drag  the  central  tendon  of  the  diaphragm  with  its 
attached  percardium  distalward  at  every  inspiration.  In  the  physiology  of  the 
stronger  inspiration  and  weaker  expiration  begins  splanchnoptosia.  The  in- 
spiratory muscles  from  sheer  force — and  to  the  crura  must  be  attributed  the 
chief  factor. 


lie  in  the  elements  of  the  wall  itself,  viz.  :  fascia,  muscle,  peritoneum,  skin 
and  elastic  fibres.  The  fine  tonus  of  the  wall,  its  delicate  elasticity  may  be 
lost.  Its  fascia  and  muscular  fibres  are  separated  and  elongated.  It  is 
flaccid  and  hangs  excessively  distalward  and  the  unsupported  viscera  follow  it. 
There  seems  to  be  a  limited  life  for  the  abdominal  walls,  as  there  is  for  the 


562  THE  ABDOMINAL  AND  PELVIC  BRAIN 

utero-ovarian  vascular  circle  of  the  genitals.  For  the  abdominal  walls  begin, 
as  a  widely  applicable  rule,  to  relax  at  about  35,  and  continue  to  relax  or 
atrophy  to  the  end  of  life.  There  can  be  no  doubt  that  the  elastic  fibres 
elongate  and  separate,  perhaps  also  atrophy,  for  the  abdominal  wall  is  not 
only  relaxed  but  is  thinned,  attenuated.  It  may  be  that  at  a  time  of  malnu- 
trition the  abdominal  walls  become  relaxed,  never  subsequently  recovering 
their  normal  state.  Relaxed  abdominal  walls  frequently  follow  continuous 
fevers,  gestation,  ascites  or  any  factor  which  increases  intra-abdominal 
pressure.  The  most  frequent  supposed  cause  of  relaxed  abdominal  wall  is 
rapidly  repeated  gestation.  In  every  gestation  physiologic  dastasis  of  the 
musculi  recti  abdominales  occur.  It  is  not  infrequent  to  find  the  recti  mus- 
cles three  inches  apart  at  the  end  of  gestation.  But  relaxed  abdominal  walls 
are  not  confined  to  women,  as  the  testimony  of  the  450  recorded  autopsies 
of  men  proved,  there  being  frequent  splanchnoptosia  in  these  subjects. 

The  pelvic,  thoracic  and  abdominal  viscera  are  liable  to  frequent  disloca- 
tion. In  visceral  inspection  of  600  adult  autopsies  I  found  local  peritoneal 
adhesions  in  over  80  per  cent.  In  other  words,  more  adult  subjects  have 
dislocated  viscera  from  peritoneal  adhesions  than  normally  situated  ones. 
The  neuro-vascular  visceral  pedicle,  the  mesentery,  becomes  elongated  and 
its  root  glides  distalward  on  the  dorsal  abdominal  wall.  The  distalward 
dislocation  of  the  dorsal  attachments  of  the  mesentery  allows  (a)  elongation 
of  the  mesentery,  (b)  an  excessive  range  of  visceral  motion,  (c)  the  abdomi- 
nal and  the  pelvic  organs  pass  distalward  and  become  impacted  in  the  pelvis, 
(d)  Splanchnoptosia  compromises  circulation  and  deranges  absorption  secre- 
tion, (e)  disorders  peristalsis,  (f)  traumatizes  nerve  periphery,  (g)  it  impairs 
nourishment,  (h)  it  produces  especially  indigestion,  (i)  it  invites  constipation. 
Splanchnoptosia  accompanies  a  defective  nervous  system  of  perhaps  congen- 
ital origin.  As  it  increases  every  decade,  after  35  years  of  age  it  is  liable  to 
cause  stenosis  or  partial  obstruction  of  the  canals,  tractus  intestinalis  from 
traction  of  one  part  and  elongation  of  other  parts  of  the  mesenteries.  It 
compromises  canalization.  The  effects  of  splanchnoptosia  (Glenard's  disease, 
1884),  on  individual  abdominal  organs,  are  varied  and  numerous. 

Intestinal    Tract. 

The  tractus  intestinalis  is  affected  chiefly  by:  (a),  compromising  of  circu- 
lation, blood  and  lymph  supply,  i.  e.,  congestion  and  decongestion,  (b) 
trauma  of  nerve  centers,  strands  and  nerve  periphery,  (c)  complication  from 
loss  of  peristalsis  and  atony  of  bowel  muscle,  (d)  gastro-intestinal  catarrh 
and  indigestion  from  excessive,  deficient  and  disproportionate  secretions, 
absorptions.  Also  dragging  on  the  abdominal  brain,  an  independent  nerve 
center  producing  nausea,  neurosis,  headache,  reflexes,  and  deranges  secretion 
and  motion  on  other  viscera,  (e)  Dilatation  of  the  stomach  and  duodenum, 
caused  by  the  superior  mesenteric  artery,  vein  and  nerve,  obstructing  the 
duodenum  at  this  point  where  they  cross  the  transverse  segment.  The 
stomach  is  especially  liable  to  dilatation  from  the  above  causes,  where  the 
prolapse  of  the  enteron  (enteroptosia)  is  sufficiently  advanced  to  allow  the 


SPLANCHNOPTOSIA 


563 


enteronic  loops  to  pass  distalward  into  the  lesser  pelvis  and  particularly 
when  the  subject  lies  on  the  back,  for  then  the  superior  mesenteric  artery, 
vein  and  nerve  are  put  on  a  stretch  and  they  constrict  vigorously  the  trans- 


f     a  V'u  diaphragm.     (Dorsal    view.)     This    illustration    presents    the  central 

tendon  and  the  attached  pericardium  with  the  powerful  right  and  left  crura.  During 
inspiration  the  diaphragmatic  crura,  immovably  fixed  by  insertion  in  the  spinal  column 
contract  drawing  the  tendon  of  the  diaphragm,  to  which  the  pericardium  is  attached, 
distalward.  bplanchnoptosia  begin  the  respiratory  organs,  i.  e.,  in  the  conquering  of  the 
inspiratory  muscles  R.  A.  R,  right  acute  fibres. 


564 


THE  ABDOMINAL   AXD   PELVIC   BRAIN 


verse  portion  of  the  duodenum,  (f)  The  enteronic  loops  being  dislocated 
(enteroptosia)  into  the  pelvis,  peristalsis,  absorption  secretion,  circulation 
and  nerve  periphery  are  compromised,  followed  by  catarrh,  constipation  and 
indigestion,  (g)  The  colon,  especially  the  colon  transversum,  may  lie  in  the 
lesser  pelvis,  producing  similar  compromising  circumstances  as  in  the 
enteron.  (h)  The  appendages  (liver,  pancreas,  and  spleen)  of  the  tractus 
intestinalis,  in  ptosis  are  compromised  in  circulation,  secretion,  absorption, 
peristalsis  and  nerve  periphery. 

Genital  Tract. 

In  splanchnoptosia  the  genital  tract  suffers,  especially  in  circulation  and 
nerve  periphery  as  well  as  secretion  and  absorption.     Uteroptosia  may  arise 
to  such  an  excessive  degree  of  mobility  that  the  uterus  may  be  forced  proxi- 
mal to  the  umbilicus  and 
in  any  portion  of  the  great 
pelvis. 

Urinary  Tract. 

The  urinary  tract  suffers 
in  splanchnoptosia,  chiefly 
from  dislocation  of  the 
kidney  (right)  nephropto- 
sia.  From  several  hun- 
dred autopsic  inspections 
and  living  abdominal  sec- 
tions, I  can  say  that  in 
many  subjects  the  kidney 
(right)  has  extensive  mo- 
tion and  is  significant  in 
gynecology,  as  its  symp- 
toms mimic  or  simulate 
genital   disturbances.     In 

my  practice  60  per  cent  of  subjects  possess  a  kidney  range  of  4  inches,  2 
inches  proximalward  and  2  inches  distalward.  Large  numbers  of  subjects 
have  a  right  kidney  range  of  3  inches,  1  1-2  inches  proximalward  and  1  1-2 
inches  distalward.  The  mobility  of  the  right  kidney  is  of  extreme  impor- 
tance in  multipara  have  a  movable  kidney  nephroptosia — proved  by 
examination  in  the  horizontal  and  erect  positions.  The  mobility  of  the 
right  kidney  is  due  to  (a)  the  longer  right  renal  artery,  (b)  the  liver  through 
the  diaphragm  forces  the  right  kidney  distalward,  (c)  muscular  trauma  of 
the  diaphragm,  quadratus  lumborum  and  constricting  waist  bands,  (d) 
absorption  of  pararenal  fat,  (e)  the  abdominal  cavity  of  woman  is  funnel- 
shaped,  with  the  large  end  of  the  funnel  distalward  and  hence  the  kidney 
receives  less  support  distally  than  it  does  in  man,  (f)  subinvolution  attacks 
the  "Wolfian  body."  (g)  The  erect  attitude.  By  continual  relaxation  of 
the  abdominal  walls  its  physiological  and  anatomic  functions  are  impaired. 


Fig.  178.  Proximal  view  of  the  pelvic  floor.  This 
illustration  is  drawn  from  my  own  dissection  (by  Dr. 
Sholer)  to  present  the  diaphragma  pelvis. 


SPLANC  IIXOPTOSIA 


565 


The  physiological  regulation  and  chief  anatomic  support  of  the  viscera  are 
unbalanced,  and  the  delicate  visceral  poise  is  lost.  The  abdominal  viscera 
move  distalward,  become  prolapsed  following  the  relaxed  abdominal  walls. 
The  condition  of  relaxed  abdominal  walls  is  followed  by  splanchnoptosia. 
Of  the  three  great  systems  of  the  abdominal  viscera,  the  tractus  genitalis, 
tractus  urinarius  and  the  tractus  intestinalis,  the  last  suffers  the  most 
severely.  Relaxed  abdominal  walls  are  followed  by  dislocated  viscera. 
A  viscus  is  dislocated  when  it  is  permanently  out  of  position.  In  general 
a  dislocated  viscus  suffers  from  trauma  of  its  nerve  periphery  and  its  blood, 
and  lymph  vascular  system  is  compromised.  Splanchnoptotic  organs 
become  hypertrophied.  Also  the  nourishment  of  a  dislocated  viscus  is  defec- 
ive,  irregular.  Dislocated  or  prolapsed  viscera  are  the  segments  of  vicious 
circles.  Relaxed  abdominal  walls  are  followed  by  partial  hernia,  especially  in 
the  pouches  of  the  most 
yielding  parts,  as  the  linea 
alba,  supraumbilical  and 
the  1  i  n  e  a  e  semilunares 
or  the  various  defective 
rings. 

In  the  following  scheme 
are  noted  not  only  the 
great  factors  in  splanch- 
noptosia, but  other  de- 
tailed factors: 

The  diaphragm. 

The  diaphragm  is  a 
muscular  barrier  anchored 
like  a  buoy  between  the 
thoracic  and  abdominal 
viscera.  It  rises  and  falls 
with  the  ebb  and  flow  of 
respiration.  There  is  a 
weaker  expiratory  flow. 

It  is  a  muscular  dome  for  the  abdominal  viscera  and  a  muscular  floor  for 
the  thoracic  viscera.  The  viscera  move  to  and  fro  with  the  diaphragm.  The 
average  height  of  the  diaphragm  is  on  a  level  with  the  fifth  costal  cartilage 
and  its  general  fluctuating  range  level  is  two  inches. 

The  variation  in  the  level  of  the  diaphragm  represents  the  phases  of  a 
respiratory  rhythm.  The  distalward  displacement  of  the  diaphragm  is  an 
essential  feature  in  splanchnoptosia.  For  the  liver,  spleen,  stomach  and 
kidneys  are  firmly  bound  to  its  abdominal  surface.  The  diaphragm  is  sup- 
ported in  its  position  first:  by  the  abdominal  muscles  forcing  the  abdominal 
viscera  proximalward  against  its  distal  concavity;  second,  it  is  supported  by 
the  thoracic  viscera;  by  fusion  of  the  pericardium  to  its  proximal  surface, 
the  heart,  great  thoracic  blood-vessels,  trachea  and  lungs  which  attach  the 


Fig.  179.  Distal  view  of  the  pelvic  floor.  This  cut  is 
drawn  by  Dr.  Sholer  from  my  own  dissection.  The 
proximal  and  distal  fascia  of  the  levator  ani  is  removed 
as  in  previous  fig. 

visceral  tide — a  stronger  inspiratory   ebb   and   a 


566  THE  ABDOMINAL  AND  PELVIC  BRAIN 

proximal  surface  of  the  diaphragm  to  the  dorsal  thoracic  wall;  third,  the 
costal  support  is  from  the  6  lower  ribs  and  spinal  support  from  the  I,  II  and 
III  lumbar  vertebrae  Hence  the  abdominal,  thoracic,  costal  and  spinal 
supports  are  required  for  a  normal  position  of  the  diaphragm.  A  defect  in 
any  support  (contraction  or  relaxation)  of  the  diaphragm  prepares  the  road 
for  splanchnoptosia. 

The  crura  of  the  diaphragm  send  strong  fibers  to  the  pericardium, 
(through  the  central  tendon)  roots  of  the  lung  (reflected  pleurae),  vena  cava, 
the  great  thoracic  vessels,  connective  tissues  of  the  oesophagus  and  trachea 
— all  diaphragm  and  thoracic  viscera,  being  solidly  and  compactly  bound 
together.  With  each  inspiration  the  crura  of  the  diaphragm  contract  on 
their  immobile  spinal  origin  and  draw  the  thoracic  viscera  (and  force  the 
abdominal)  distalward.  The  vigorous  contraction  of  the  diaphragmatic  crura 
(in  inspiration)  is  the  most  important  factor  in  producing  incipient  splanch- 
noptosia. For  reasons,  not  fully  known,  the  (inspiratory)  diaphragmatic 
supports  of  certain  individuals  yield  and  splanchnoptosia  begins.  The  yield- 
ing of  the  diaphragm  supports  occur  first  in  the  muscles  of  inspiration. 
The  diaphragm  (especially  the  crura)  during  contraction  (inspiration)  forces 
the  mediastinal  contents — heart  (pericardium),  trachea  and  oesophagus — 
distalwards,  which  elongates  the  mediastinal  mesentery,  composed  of  pleural 
reflections.  By  viewing  a  patient  laterally  with  the  fluoroscope  the  heart 
may  be  observed  to  move  proximalward  and  distalward  during  respiration. 
The  range  of  proximalward  and  distalward  action  of  the  heart  (and  conse- 
quently the  diaphragm  which  is  fixed  to  the  pericardium)  is  considerable 
especially  in  subjects  with  abdominal  type  of  respiration  and  in  such  the 
distalward  movements  of  the  heart  is  the  greater. 

Influence  of  DiapJiragm  in  Splanchnoptosia. 

When  the  diaphragmatic  supports  begin  to  yield  the  inspiratory  distal- 
ward movements  (displacements)  of  the  thoracic  viscera  are  a  cause  of  incip- 
ient splanchnoptosia.  Since  the  pericardium  is  not  only  solidly  attached  to 
the  diaphragm  but  is  also  solidly  attached  to  the  roots  of  the  lung,  thoracic 
vessels,  oesophagus  and  trachea  a  movement  of  the  diaphragm  (induced 
chiefly  by  crural  contractions)  must  be  accompanied  by  movements  of  the 
thoracic  viscera.  In  short,  the  diaphragm  is  connected  to  the  mediastinum, 
pericardium  root  of  lung,  thoracic  vessels,  oesophagus  trachea,  vagi  and  the 
respiratory  expansion  is  gained  chiefly  by  a  distalward  movement  of  the  dia- 
phragm accompanied  by  the  thoracic  viscera — lungs  and  heart.  It  is  when 
this  distalward  movement  of  the  diaphragm  (inspiration)  becomes  excessive 
(from  relaxation  of  diaphragmatic  supports)  that  splanchnoptosia  begins. 
(We  will  at  present  not  dispute  that  atonia  gastrica  abdominal  relaxation 
develops  concomitant  as  respiration  includes  the  abdominal  muscles.)  The 
diaphragm  is  a  digastric  muscle  with  two  origins  viz. :  (a)  spinal  origin 
(vertebral  column — crura — and  arcuate  fibers;  (b)  ventral  origin  (from  the  6 
lower  ribs)  and  by  the  contractions  of  its  two  bellies  enhances  thoracic  space 
for  inspiration,  therefore  its  share  in  incipient  splanchnoptosia  is  evident. 


SPLANCHNOPTOSIA 


567 


From  the  above  evidence  it  is  obvious  that  the  distalward  movements  of  the 
diaphragm  (in  respiration)  will  depend  on  the  opposition  offered  by  the 
abdominal  viscera  through  the  strength  of  the  abdominal  wall,  as  well  as  the 
mobility  of  the  6  lower  ribs.  If  the  muscles  of  the  abdominal  wall  offer 
normal  resistance  to  the  distalward  movements  of  the  abdominal  viscera  the 
diaphragm  will  be  supported  by  the  abdominal  viscera  (liver,  spleen,  pan- 
creas, stomach,  kidneys)  and  cannot  descend.  However,  if  atonia  gastrica 
(abdominal  relaxation)  exist  the  diaphragm  shares  in  the  thoracic  and  abdom- 
inal splanchnoptosia  with  consequent  abdominal  type  of  respiration.  If, 
however,  the  contraction  of  the  diaphragm  (crura)  cannot  force  the  abdomi- 
nal viscera  distalward  the  thoracic  viscera  must  expand  (in  respiration) 
within  the  thorax  with  consequent  thoracic  type  of  respiration.  Splanch- 
noptoses experience  abdominal  types  of  respiration. 

Spinal    Segment. 

The  spinal  segment  of  the  diaphragm  has  a  constant  function,  i.  e.,  its 
contraction  (inspiration)  forces  both  thoracic  and  abdominal  viscera  distal- 
ward. The  ventral  segment  of  the  diaphragm  is  otherwise  for  its  action  on 
the  lower  6  ribs  depends 
on  the  position  of  the  ribs. 
If  the  lower  6  ribs  become 
misplaced  the  action  of 
the  diaphragmatic  muscles 
become  altered.  The  ab- 
dominal type  of  respira- 
tion signifies  that  the  pul- 
monary space  is  gained 
chiefly  by  the  expansion 
of  the  distal  end  of  the 
thorax.  The  thoracic  type 
of  respiration  signifies  that 
the  pulmonary  space  is 
gained  mainly  by  the  ex- 
pansion of  the  proximal 
end  of  the  thorax.  1.  It 
may  be  noted  therefore 
that  the  fixation  of  the 
thoracic  viscera  is  through:  (a)  the  thoracic,  diaphragmatic  and  abdominal 
muscles;  (b)  thoracic  vessels;  (c)  the  oesophagus;  (d)  the  trachea;  (e)  the 
pericardium;  (f)  dorsal  thoracic  mesentery  (reflected  plurae);  (g)  the  thoracic 
fascia;  (h)  vagi  and  phrenic  nerves.  2.  The  motion  of  the  thoracic  viscera 
is  noted  through:  (a)  the  expansion  (inspiration)  of  the  chest;  (b)  the 
movements  of  the  diaphragm ;  (c)  the  motion  of  the  abdominal  wall.  The 
thoracic  diaphragm  is  one  of  the  most  important  respiratory  muscles. 
It  is  innervated  by  a  single  nerve  (Phrenic)  therefore  it  contracts,  func- 
tionates,   as    a    single    muscle.       Diaphragma    thoracis   serves  as  a    floor, 


Fig.  180  represents  a  normal  transverse  segment  of 
the  abdominal  wall.  About  the  umbilicus.  1,  rectus;  2, 
skin;  3,  fascia;  4,  fascia;  5,  external  oblique;  7,  trans- 
versalis  ;  8,  peritoneum  ;  9,  linea  semilunaris  ;  10,  linea 
alba;  11,  spinal  muscles;  12,  quadratus  lumbarium ;  13, 
psoas  muscle ;  15,  vena  cava,  and  16,  aorta. 


568 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


a  support  for  the  thoracic  viscera.  Its  peripheral  origin  is  from  the 
sterum,  ribs  (lower  6),  and  lumbar  vertebras  (I  to  III).  Its  fibers  are  inserted 
in  the  central  tendon.  Its  special  fixum  punctum  is  the  vertebral  column. 
Its  punctum  mobile  is  the  centrum  tendineum  with  the  two  apertures 
(vena  cava  and  oesophagus.  The  aortic  aperture  is  practically  immobile). 
Diaphragma  thoracis  resembles  diaphragma  pelvis  in  physiology  and 
anatomy.  Both  have  (a)  a  similar  fixum  punctum,  (circular  bony  origin) ; 
(b)  similar  punctum  mobile  (central  tendon);  (c)  both  support  super- 
imposed viscera ;  (d)  both  have  3  apertures  for  visceral  transmission ;  (e)  both 
diaphragms  are  respiratory;  (f)  both  muscles  by  constriction  limit  the 
apertures  of  visceral  transmission ;  (g)  both  contract  as  a  single  muscle ;  (h) 
both  share  in  splanchnoptosia.  They  differ  in  that  contraction  of  the  pelvic 
diaphragm   draws  the  3  visceral  apertures  proximalward,  and  ventralward, 

while  contraction  of  the 
thoracic  diaphragm  draws 
the  visceral  apertures  dis- 
talward  and  dorsalward. 
Distalward  movement  of 
the  thoracic  diaphragm  in 
splanchnoptosia  trauma- 
tizes, injures,  stretches 
the  phrenic  and  vagi 
nerves  hence  will  derange 
respiration  (inducing  neu- 
rosis). 

Derangement  of  respi- 
ration is  clinically  evident 
among  splanchnoptostics. 

Fixation  and  Motion  of  the 
Thoracic  Viscera. 


Fig.  181  illustrates  a  transverse  section  of  the  abdo- 
men, about  the  umbilicus  of  a  splanchnoptotic.  The 
fascial  and  muscular  fibres  of  the  abdominal  wall  are 
elongated  and  separated,  the  primary  factor  in  the  splanch- 
noptosis, 1,  rectus;  2,  linea  alba;  3,  5,  linea  semilunaris; 
6,  skin;  7,  fascia;  8,  external  oblique;  9,  internal  oblique; 
10,  transversalis;  11,  transversalis  fascia;  12,  the  peri- 
toneum; 13,  vena  cava;  14,  aorta;  16,  quadratus  lum- 
borum  ;  15,  psoas;  17,  vertebra;  18,  spinal  nucleus. 


Splanchnoptosia  begins 
in  the  deranged  anatomy 
and  physiology  of  the 
tractus  respiratorius.  At 
every  inspiration  the 
crura  of  the  diaphragm 
contracts  on  the  pericar- 
dium (which  is  fixed  to  the  diaphragm)  which  in  turn  drags  on  the  great 
thoracic  vessels  which  finally  tugs  on  the  mediastinal  structures  (oesophagus, 
trachea  and  pulmonic  mesentery)  carrying  the  thoracic  viscera  and  forcing  the 
abdominal  viscera  distalward.  The  viscera  are  poised  between  the  two  great 
systems  of  inspiratory  and  expiratory  muscles  which  are  arrayed  in  rhythmic 
opposition  during  life. 

The  victory  of  the  inspiratory  muscles  over  their  opponent,  the  expiratory 
muscles,  is  the  beginning  of  splanchnoptosia. 


SPLANCHNOPTOSIA  569 

Students  should  be  taught  that  not  only  the  muscles  of  the  thoracic  wall 
belong  to  respiration  but  also  the  abdominal  muscles  are  an  integral  part. 
The  thoracic  and  abdominal  muscles  are  a  breathing  apparatus.  Man's 
respiratory  muscles  extend  from  face  to  pelvic  floor. 

The  XII  intercostals  with  the  I  and  II  lumbar  nerves  practically  supply 
the  muscles  of  respiration  which  extend  from  manubrium  to  symphysis 
pubis. 

A  knowledge  of  the  movements  of  the  viscera  during  respiration  indicates 
the  method  and  location  of  their  fixation  within  the  thoracic  and  abdominal 
cavities. 

Any  prominent  deviation  of  the  respiratory  muscles  is  accompanied  by 
deranged  visceral  movements  resulting  in  splanchnoptosia,  disordered  ana- 
tomy and  physiology.  We  will  devote  a  few  remarks  to  the  diaphragm  in 
splanchnoptosia. 

The  Respiration  in  Splanchnoptosia  {irregular). 

The  prominent  symptoms  of  the  respiration  in  splanchnoptosia  are  short- 
ness of  breath,  irregular  long  respiration,  difficult  breathing  and  asthmatic 
breathing  with  cardiac  palpitation.  The  relaxed  abdominal  muscles,  the 
respiration  muscles,  have  lost  their  power  and  perfect  muscular  relaxation  is 
not  possible.  Complete  respiration  is  muscular  relaxation  and  contraction. 
In  the  erect  attitude  the  dislocated  liver  drags  on  the  diaphragm  through  its 
coronary  ligaments,  and  through  the  vena  cava.  Besides,  the  liver  is  in  turn 
dragged  on  by  the  tractus  intestinalis  through  its  two  ligaments  attached 
to  the  liver,  viz.,  ligamentum  hepato-colicum  and  ligamentum  hepato-cavo- 
duodenale,  resulting  in  disturbance  of  a  respiratory  organ — the  diaphragm. 
The  irregular  respiration — a  frequent  symptom  of  relaxed  abdominal  walls 
and  consequent  splanchnoptosia — is  another  link  in  the  viscious  circle, 
because  it  imperfectly  and  irregularly  oxidizes  the  blood,  disturbing  nutrition. 

CONSIDERATION  OF  VISCERAL  FIXATION  IN  SPLANCHNOPTOSIA. 

Fixation  and  Movement  of  A  bdominal  Viscera. 

(a)  Abdominal  viscera  fixed  immovably  in  position  {to  radix  mesentericd) 
not  sharing  in  respiratory  movements  {duodenojejunal  flexure  and  body  of 
pancreas).  I  examined  the  viscera  of  numerous  quadrupeds,  some  20  mon- 
keys, apes,  baboons  (i.  e.,  animals  which  sit  or  stand  practically  erect  in  life) 
and  several  hundred  humans.  The  testimony  from  the  investigations  is  that 
the  more  the  animal  lives  in  the  erect  attitude  the  more  firmly  and  extensively 
are  the  viscera  fixed  to  the  abdominal  walls.  The  extensive  and  firm  fixation 
of  abdominal  viscera  to  the  abdominal  walls  found  in  man  (and  erect  apes) 
marks  the  final  process  developing  in  erect  animals.  However  firm  and 
extensive  the  fixation  of  viscera  to  the  abdominal  wall,  it  plays  a  minor 
role  in  the  prevention  or  cure  of  splanchnoptosia,  in  comparison  with  dia- 
phragm and  muscular  abdominal  walls.  I  found  marked  relaxed  abdominal 
walls  and  advanced  splanchnoptosia  in  erect  apes.  The  method  of  abdom- 
inal visceral  fixation  may  now  be  considered. 


570  THE  ABDOMINAL   AND  PELVIC  BRAIN 

Through  the  courtesy  of  Prof.  W.  A.  Evans  I  was  sufficiently  fortunate  to 
secure  an  autopsy  on  the  orang  recently  dying  in  the  Lincoln  Park  Zoologic 
department.  This  human-like  orang,  a  native  of  Borneo,  was  a  female  some 
10  years  of  age  and  weighed  80  pounds.  The  thoracic  and  abdominal  vis- 
cera resembled  those  of  man  in  relation  (to  peritoneum),  form,  fixation  and 
motion.  The  appendix  was  precisely  typical  of  man,  six  inches  in  length, 
and  was  located  in  the  pelvis  (woman's  appendix  lies  in  the  pelvis  in  48  per 
cent  of  subjects).  The  coecum  rested  on  the  psoas  muscle,  however,  since 
the  orang  does  not  walk  (but  sits)  the  psoas  had  not  produced  sufficient 
trauma  to  cause  pericoecal  peritoneal  adhesions.  The  colon  in  all  its  seg- 
ments resembles  that  of  man  in  relation,  form,  fixation  and  motion.  The 
transverse  colon  measured  12  inches  while  the  sigmoid  flexure  measured  13 
inches  in  length. 

In  one  matter  of  degree  (not  of  difference)  the  colon  presented  more 
numerous  appendicae  epiploicae  than  that  of  man.  The  fixation  of  the 
viscera  on  the  dorsal  abdominal  wall,  the  location  of  the  mesenteries,  and 
the  radix  mesenterica,  the  relation  of  pancreas,  liver,  duodenum,  stomach 
and  spleen  were  duplicates  of  homo.  The  omentum  majus  resembling  man's 
(except  its  blades  had  not  completely  coalesced)  ceased  at  the  flexura 
hepatica.  The  tractus  genitalis  in  relation  (to  peritoneum),  form,  fixation 
and  location  precisely  resemble  that  of  man.  In  the  orang  the  relation  (to 
peritoneum  and  viscera)  of  the  diaphragm,  the  most  important  respiratory 
apparatus,  precisely  resembles  that  of  man  in  location,  relation,  fixation  and 
motion.  The  psoas  muscle  was  relatively  not  so  large  as  that  of  man  because 
the  orang  does  not  walk  (practically  lives  sitting).  In  the  orang  especially, 
but  also  in  the  human-like  apes,  baboon,  monkeys  I  found  that  their  viscera 
were  similarly  developed  and  point  for  point  was  fixed  in  detail  similar  to 
those  of  man.  The  method  of  visceral  fixation  in  man  is  due  to  respiration 
and  attitude. 

Radix  Mesenterica. 

The  radix  mesenterica  or  root  of  the  mesentery  consists  of  the  coeliac 
axis  and  superior  mesenteric  artery  encased  by  its  fibro-muscular  sheath  (pro- 
longed from  the  sheath  of  the  aorta  and  diaphragmatic  crura).  The  root  of 
the  mesentery  (major  visceral  arteries)  arise  from  the  aorta  as  it  enters  the 
abdominal  cavity  between  the  crura  diaphragmatica  and  at  the  junction  of 
the  intercrural  arch  through  which  the  aorta  encased  in  its  fibrous  sheath 
enters  the  abdominal  cavity  may  be  termed  the  hilum  of  the  peritoneum.  In 
a  limited  area  located  at  the  root  of  the  mesentery  only  is  the  abdominal 
viscera  immovably  fixed  in  position.  The  root  of  the  mesentery  is  the  solid 
immovable  center  around  which  the  abdominal  viscera  play  in  the  ebb  and 
flow  of  respiration. 

From  the  root  of  the  mesentery  (coeliac  and  superior  mesenteric  arteries) 
radiate  strong  fibrous  bands  from  the  sheath  of  the  aorta  and  fibro-muscular 
bands  from  the  diaphragmatic  crura,  on  the  peripheral  arterial  trunks  toward 
the  viscera  (stomach,  spleen,  liver,  pancreas  and  enteron)     At  the  root  of  the 


splanchnoptosis! 


571 


mesentery  is  located  the  solar  plexus,  ganglion  coeliacum  (abdominal  brain) 
which  emits  rich  plexiform  network  of  nerves  along  the  fibrous  sheaths  of  the 
arterial  trunks  to  the  viscera.  Numerous  lymphatic  vessels  pass  along  the 
vascular  sheath.  A  considerable  fibro-muscular  band,  muscle  of  Treitz 
(musculus  suspensorius  duodeni),  (Wenzel  Treitz,  Bohemian,  1819-1874,  Prof. 


Fig.  182.  This  figure  illustrates  the  viscera  of  a  female  orang  from  Borneo. 
Its  age  was  about  ten  years.  App.,  appendix,  six  inches  long,  lying  on  the 
pelvic  floor;  U.,  uterus;  C,  coecum ;  F.S.,  signoid  flexure;  Am.,  oviductal 
ampulla;  Ov.,  ovary;  St.,  stomach;  G.,  gall  bladder;  L.,  liver;  hook  drawing 
the  severed  omentum  majus  proximalward. 

Pathology  in  Prague)  is  emitted  from  the  diaphragmatic  crura  (right  or  left) 
to  terminate  in  the  duodeno-jejunal  flexure  binding  it  solidly  to  the  root  of 
the  mesentery. 

The  dorsal  surface  of  the  corpus  pancreaticus  is  solidly  and  firmly  bound 
by  strong  fibrous  tissue  in  the  fork  between  the  coeliac  and  superior  mesen- 
teric arteries.     Hence  whatever  form  of  splanchnoptosia  may  afflict  other 


572 


THE  ABDOMINAL   AXD   PELVIC  BRAIX 


abdominal  viscera  the  duodenojejunal  flexure  and  the  middle  of  the  body  of 
the  pancreas  remain  fixed,  immovably,  in  position.  The  radix  mesenterica, 
root  of  the  mesentery,  is  immovably  fixed  in  position  and  hence  does  not 
move  in  respiration.     The  duodenal-jejunal  flexure  and  body  of  the  pancreas 

are  firmly  fixed  to  the  root 
of  the  mesentery  and  hence 
do  not  share  in  respiratory 
movements  of  the  viscera. 
All  abdominal  viscera  (ex- 
cept those  fixed  to  the  root 
of  the  mesentery  as  the  duo- 
deno  -  jejunal  flexure  and 
body  of  the  pancreas)  are 
fixed  to  the  abdominal  wall 
and  therefore  share  in  re- 
spiratory movements.  (Re- 
mark:—  From  the  above 
anatomic  facts  reports  of  ex- 
tensive hernia  do  not  record 
the  pancreas  or  duodenum  as 
having  passed  through  the 
hernia  ring  into  the  hernial 
sac.) 

(b)  A  bdominal  viscera 
fixed  to  the  abdominal  wall 
and  sharing  in  respiration. 
(The  only  exception  are  the 
duodenojejunal  flexure  and 
pancreas.)  A  brief  ref- 
erence to  the  fixation  of  in- 
dividual viscera  to  the  ab- 
dominal wall  and  their  share 
respiratory     movements 


ID 


Fig.  183.  The  areas  of  peritoneum  shown  at  25  and 
27,  as  well  as  at  34  and  11,  also  at  5,  8,  12,  14,  are  addi- 
tional aids  to  support  the  viscera.  They  are  practical 
extensions  of  the  mesenterial  bases.  The  granular  areas 
are  the  mesenterial  bores,  while  the  intervening  areas 
are  where  the  peritoneum  is  fixed  to  the  abdominal  wall. 

will  now  be  made  in  or- 
der to  comprehend  the  nature  and  anatomy  of  the  vast  domain  of  splanch- 
noptosia. 

Fixation  of  Tractus  Intestinalis. 

The  degree  of  firmness  and  extent  of  fixation  of  the  tractus  intestinalis 
increases  with  the  erect  attitude.  The  erect  apes  and  man  form  the  culmi- 
nation of  extensive  fixation  of  abdominal  viscera.  The  erect  attitude  is 
responsible  for  splanchnoptosia.  From  careful  examination  of  the  viscera  of 
mammals,  monkey  and  erect  apes,  it  is  evident  to  me  that  all  these  animals 
progress  through  precisely  the  same  stages  of  visceral  development  and  that 
visceral  fixation  is  exactly  the  same,  analogous  in  all— the  chief  change  in  all 
the  visceral  fixation  is  due  to  attitude  (erect)  and  respiration. 


SPLANCHNOPTOSIA  573 

In  the  fixation  of  abdominal  viscera  there  must  be  held  in  view  (a)  the 
abdominal  wall;  (b)  respiration  and  erect  attitude;  (c)  the  mesenteries — their 
basal  organ  and  method  of  insertion  on  the  abdominal  wall.  The  mesenteries 
are  not  for  mechanic  support  but  for  the  conduction  of  nerves,  vessels  and 
prevention  of  visceral  entanglement.  The  mesenteries  separate  the  viscera 
into  compartments  which  enables  them  to  be  supported  with  greater  facility 
by  means  of  visceral  shelves.  I.  The  primary  visceral  support  except  the 
abdominal  wall  is  vascular:  (a)  coeliac  axis;  (b)  the  superior  mesentery 
artery;  (c)  the  inferior  mesentery  artery.  II.  The  secondary  visceral  sup- 
port to  the  abdominal  wall  is  peritoneal  adhesions  (cellular-non-pathologic). 
In  splanchnoptosia  the  base  or  insertion  of  the  mesentery  on  the  dorsal 
abdominal  wall  may  glide  distalward.  The  basal  fixation  of  the  foetal 
mesentery  is  unlike  that  of  the  adult.  The  base  of  the  foetal  mesentery 
contains  the  cells,  which  later  multiply,  spreading  into  the  broad  base  of 
the  adult  mesentery  that  lends  to  erect  man  his  extensive  width  of  mesenteric 
adhesions. 

A  few  remarks  should  be  made  as  regards  the  acquired  mesenteric  adhe- 
sions of  erect  man. 

/.     Mesogastric  Adhesions. 

In  quadrupeds  like  the  cat  the  origin  or  root  of  the  mesogastrium  is  at 
the  coeliac  artery,  the  radix  mesenterica.  With  the  erect  attitude  the  root 
of  the  mesogastrium  becomes  increasingly  adherent  to  the  dorsal  abdominal 
wall  in  an  oblique  line.  From  the  coeliac  axis,  the  mesogastric  root,  the 
adhesions  spread  leftward  over  the  adrenal  and  kidney  to  the  spleen  which  is 
attached  to  the  mesogastrium.  In  embryos  and  infants  one  can  trace  the 
development  of  the  mesogastric  adhesions  from  the  single  point,  the  radix 
mesenterica  to  the  extensive  adhesions  of  adult  man.  The  mesogastric 
adhesions  or  insertion  on  the  dorsal  wall  aids  in  the  fixation  of  the  stomach. 

2.     Mesoduodenal  Adhesions. 

The  duodenal  loop  is  early  in  the  human  embryo  entirely  free,  non- 
adherent, and  is  still  free  in  adult  lower  mammals.  Gradually  in  man  the 
rightward  movement  of  the  liver  draws  the  duodenal  loop  with  it  and  the 
right  side  of  the  mesoduodenum  loses  its  endothelium  and  its  mesenterii 
membrana  propria  becomes  adherent  to  'he  right  dorsal  wall  and  especially 
to  the  renal  hilum.  In  dissection  and  operations  in  the  biliary  passages  the 
mesoduodenal  adhesions  are  released  with  facility.  However,  the  mesoduo- 
denal adhesions  afford  a  strong  support  to  the  duodenum  itself  and  also  make 
of  the  duodenum  a  solid  visceral  shelf  for  the  liver  and  stomach.  The 
mesoduodenal  adhesions  are  especially  solid  dorsal  to  the  line  crossed  by 
the  colon  (coecum)  in  its  journey  to  the  right  iliac  fossa. 

The  duodenum  is  the  most  fixed  segment  of  the  tractus  intestinalis  due 
to:  (a)  the  muscles  of  Treitz;  (b)  the  extensive  fixation  of  the  mesoduode- 
num ;  (c)  ligamentum  hepato-duodenale;  (d)  biliary  passages;  (e)  pancreas  (the 
body  of  which  is  solidly  fixed  to  the  coeliac  axis).     Observe  the  absence  of 


574  THE  ABDOMINAL  AND  PELVIC  BRAIN 

the  duodenum  (and  the  pancreas)  in  hernial  reports  on  account  of  their  solid 
fixation  to  the  immobile  radix  mesenterica. 

3.     Mescnteronic  Adhesions. 

The  mesenteronic  adhesions  (of  man)  extend  some  six  inches  in  an 
oblique  line  from  the  duodeno-jejunal  flexure  to  the  coecum.  Originally  in 
features  the  mesenteron  and  mesocolon  were  in  one  line,  and  fan-shaped, 
being  attached  by  its  apex  to  the  coeliac  axis  or  radix  mesenteria.  With 
development  of  the  tractus  intestinalis  a  rotation  occurred  on  the  radix  mesen- 
terica and  the  coceum  journeyed  to  the  right,  crossing  ventrally  to  the 
duodenum,  forming  extensive  acquired  fixations  for  the  testinal  tract.  The 
extent  of  the  mesenteronic  adhesions  (which  are  on  the  right  side)  depends 
on  the  degree  of  distalward  movement  acquired  by  the  coecum.  Frequently 
(9  per  cent  in  man  and  5  per  cent  in  woman  according  to  my  700  autopsies) 
the  journey  of  the  coecum  to  the  right  iliac  fossa  becomes  interrupted  (non- 
descent  of  coecum)  at  any  point  distal  to  the  liver.  In  such  a  case  the 
mesenteron  (except  the  duodenum)  and  a  corresponding  pact  of  the  trans- 
versum  and  right  colon  are  suspended  practically  (without  adhesions)  by  the 
radix  mesenteria,  i.  e.,  the  superior  mesenteric  artery  (as  it  originates  from 
the  aorta  about  one-half  inch  from  the  coeliac  axis). 

Not  long  before  birth  (man)  the  mesenteronic  adhesions  beginning  at  the 
transverse  (or  right)  colic  margin  radiate  distalward  toward  the  right  ilias 
fossa.  From  dissection  it  will  be  observed  that  with  normal  mesenteronic 
adhesions,  the  chief  enteronic  support  is  practically  the  radix  mesenteria, 
i.  e.,  the  arteria  mesenterica  superior.  This  can  be  demonstrated  with 
facility  in  the  dead.  However,  the  mesenteronic  adhesions  lend  solid  support 
to  the  enteron  aiding  to  a  high  degree  to  prevent  enteroptosia. 

4.     Mesocolic  Adhesions. 

Acquired  mesocolic  adhesions  in  the  erect  attitude  assume  two  directions, 
viz. :  (a)  those  of  the  left  colon;  (b)  those  of  the  right  colon.  Originally  the 
mesocolon  was  located  in  the  medium  line.  With  development  of  the  foetus 
the  left  mesocolic  blade  becomes  adherent  to  the  lumbar  wall  especially  the 
splenic  flexure  becomes  fixed  to  the  ventral  surface  of  the  left  kidney  and  the 
left  colon  becomes  fixed  to  the  lumbar  wall  as  far  as  the  intersigmoid  fossa. 
This  extensive  peritoneal  adhesion  in  the  lumbar  region  added  to  the  vas- 
cular support  (inferior  mesenteric  artery)  reinforces  to  a  high  degree  the 
effective  fixation  of  the  left  colon.  It  also  forms  a  peritoneal  compartment 
for  enteronic  loops. 

(b)     Adhesions  of  the  Right  Colon. 

By  peritoneal  adhesions  of  the  transverse  colon,  the  hepatic  flexure  and 
right  colon  are  fixed  in  position.  The  coecum  and  appendix  being  projections 
from  the  original  digestive  tube  possess  no  peritoneal  adhesions  to  the  abdom- 
inal wall.  In  all  erect  apes  examined  as  to  the  right  colon  I  found  the  same 
exact  condition  of  peritoneal  adhesions  as  man  except  that  in  man  the  axial 
rotation  of  the  tractus  intestinalis  was  more  advanced  or  complete  ending 


SPLAAC11N0PT0SIA  575 

with  coecum  in  the  right  iliac  fossa  or  in  the  lesser  pelvis.  In  man  the  peri- 
toneal adhesions  of  the  right  colon  are  more  extensive  than  that  of  the  left 
colon  (which  seldom  possesses  a  mesocolon).  The  adhesions  fixing  the 
duodenum  to  the  abdominal  wall  and  the  adhesions  fixing  the  right  colon  to 
the  abdominal  wall  are  practically  developed  at  the  same  time.  The  adhe- 
sions of  the  right  colon  spreads  over  the  mesoduodenum,  duodenum,  distal 
ventral  face  of  the  right  kidney  and  right  lumbar  region.  The  mesocolon 
being  fixed  to  the  immobile  mesoduodenum  lends  strong  support  to  the 
fiexura  colihepatica.  The  transverse  colon  and  hepatic  flexure  of  the  colon 
secure  additional  peritoneal  fixation  apparatus  from  the  fact  that  as  soon 
as  the  rotating  coecum  comes  in  contact  with  the  ballooned  mesogastrium  a 
fusion  of  the  mesogastrium  and  mesocolon  from  base  to  viscera  occur. 
Finally  the  mesogastrium  (or  rather  gastro-colic  omentum)  envelopes  the 
entire  proximal  segment  of  the  colon. 

On  the  left  colon  there  is  an  important  fixation  apparatus  known  as  the 
ligamentum  costo-colicum  (sinistrum)  located  on  the  ventral  surface  of  the 
left  kidney.  On  the  right  colon  there  is  a  similar  fixation  apparatus  liga- 
mentum costo-colicum  (dextrum)  located  at  the  distal  pole  of  the  right 
kidney.  This  band  prevents  frequently  the  coecum  from  further  distalward 
movements  and  also  from  falling  into  the  lesser  pelvis.  The  ligamentum 
costo-colicum  dextrum  is  an  important  fixation  apparatus  for  the  coecum 
(and  appendix)  and  prevents  frequently  the  coecum  from  being  a  resident 
in  the  lesser  pelvis.  Not  infrequently  the  ligamentum  costo-colicum  dextrum, 
together  with  the  right  colon,  offers  more  or  less  support  to  the  right  kidney 
especially  at  its  distal  pole.  At  birth,  so  far  as  I  am  able  to  report  on  some 
60  infant  autopsies,  the  coecum  lies  in  general  at  the  junction  of  the  duode- 
num and  kidney. 

The  peritoneal  adhesions  of  the  right  colon  are  formed  while  the  child  is 
learning  to  walk,  i.  e.,  by  the  end  of  18  months.  The  peritoneal  adhesions 
of  the  tractus  intestinalis  (secondary  visceral  supports)  to  the  dorsal  wall  of 
the  abdomen  reinforce  to  remarkable  degree  the  strength  of  the  primary 
visceral  supports  (arteria  coeliaca,  mesenterica  superior  et  inferior).  The 
secondary  visceral  supports  (acquired  peritoneal  adhesions  form  visceral 
shelves),  the  contact  of  the  viscera,  like  bricks  in  a  wall,  form  solid  barriers 
for  visceral  support.  The  mesenterial  partitions  among  the  viscera,  producing 
peritoneal  compartments  aid  in  visceral  support  by  distributing  their  force 
separately  against  the  abdominal  wall. 

Respiration  Movements  of  the  Tractus  Intestinalis. 

The  transverse  colon  moves  freely  with  respiration  as  it  is  a  shelf  for 
the  sub-diaphragmatic  viscera  (stomach,  liver  and  spleen).  The  fiexura  coli 
dextra  (lying  ventral  to  the  right  kidney)  and  the  fiexura  coli  sinistra  (lying 
ventral  to  the  left  kidney)  move  with  the  kidneys  in  respiration.  Since  the 
transverse  mesocolon  acts  as  a  visceral  shelf  it  is  markedly  forced  distalward 
during  splanchnoptosia,  especially  in  enteroptosia.  I  have  seen  it  lying  on  the 
pelvic  floor  and  once  9  inches  in  an  inguinal  hernia,  where  as  its  average 


576  THE  ABDOMINAL  AND  PELVIC  BRAIN 

location  is  immediately  proximal  to  the  umbilicus.     The  two  colonic  flexures 
in  coloptosia  produce  vigorous  traction  in  the  kidneys. 

In  the  usual  autopsy  the  enteron  is  found  in  a  compartment  formed  by 
the  mesocolonic  square  and  closed  ventrally  by  the  omentum  majus.  The 
transverse  mesocolic  shelf  prevents  the  subdiaphragmatic  viscera  from 
exercising  vigorous  respiratory  movements  on  the  enteron.  Defective  res- 
piratory movements  of  the  diaphragm  will  aid  in  forcing  the  enteron  distal- 
ward,  from  the  right  and  left  lumbar  regions,  into  the  lesser  pelvis.  In  final 
advance  states  of  enteroptosia,  the  transverse  segment  of  the  duodenum 
becomes  obstructed  by  the  traction,  compression  of  the  superior  mesenteric 
artery,  vein  and  nerve — a  distant  stage  in  splanchnoptosia. 

The  tractus  intestinalis  is  affected  chiefly  in  splanchnoptosia  by:  (a) 
compromising  of  circulation,  blood  and  lymph  supply,  i.  e.(  congestion  and 
decongestion,  (b)  trauma  of  nerve  centers  (ganglia),  strands  and  nerve 
periphery,  (c)  complication  from  loss  of  peristalsis  and  atony  of  bowel  mus- 
cle, (d)  gastro-intestinal  catarrah  and  indigestion  from  excessive,  deficient 
and  disproportionate  secretions.  Also  dragging  on  the  abdominal  brain,  an 
independent  nerve  center  producing  nausea,  neurosis,  headache,  reflexes,  and 
deranged  sensation,  secretion  and  motion  on  other  viscrea.  (e)  Dilatation  of 
the  stomach  and  duodenum,  caused  by  the  superior  mesenteric  vessels  at  the 
point  where  they  cross  the  transverse  segment.  The  stomach  is  especially 
liable  to  dilatation  from  the  above  causes,  where  the  prolapse  of  the  enteron, 
enteroptosia,  is  sufficiently  advanced  to  allow  the  enteronic  loops  to  pass 
distalward  into  the  lesser  pelvis  and  particularly  when  the  subject  lies  on  the 
back,  for  then  the  superior  mesenteric  artery,  vein  and  nerve  are  put  on  a 
stretch  and  they  constrict  vigorously  the  transverse  portion  of  the  duodenum, 
(f)  the  enteronic  loops  being  dislocated  (enteroptosia)  into  the  plevis,  peri- 
stalsis, secretion,  circulation,  sensation  and  nerve  periphery  are  compromised, 
followed  by  catarrh,  constipation  and  indigestion,  (g)  the  colon,  especially 
the  colon  transversum  may  lie  in  the  lesser  plevis  producing  similar  com- 
promising circumstances  as  in  the  enteron.  (h)  The  appendages  (liver, 
pancreas,  and  spleen)  of  the  tractus  intestinalis,  in  ptosis  are  compromised 
in  circulation,  secretion,  absorption,  sensation  and  nerve  periphery. 

CONSIDERATIONS  OF  GASTROPTOSIA  AS   PART  OF  SPLANCHNOPTOSIA. 

The  stomach  is  fixed  to  the  diaphragm  by  the  oesophagus  and  part  of  the 
gastro-hepatic  omentum  (peritoneum).  It  is  fixed  to  the  liver  by  the  gastro- 
hepatic  omentum  (peritoneum),  hepatic  artery,  biliary  duct  and  ligamentum 
hepato-duodenale  and  peritoneum  (all  important  bands).  The  stomach  is 
fixed  to  the  radix  mesenterica  by  the  gastric  artery.  The  root  of  the  mesen- 
tery is  not  only  an  important  gastric  support,  but  a  solid  anchor,  around 
which  occur  all  visceral  movements.  Besides  the  stomach  rests  on  visceral 
shelves  composed  of  the  transverse  colon  and  its  mesentery,  pancreas, 
duodenum  and  left  kidney.  It  is  maintained  on  the  visceral  shelves  by  the 
abdominal  muscles.  The  distal  end  of  the  stomach  is  bound  to  the  diaphragm 
through  the  liver  (gastro-hepatic  and  meshepaticon)  and  in  a  similar  manner 


SPLANCHNOPTOSIA 


577 


the  proximal  end  of  the  stomach  is  bound  to  the  diaphragm,  through  the 
spleen  (gastro-splenic,  lienorenal  and  suspensory  ligament)  which  i?,  how- 
ever, a  band  of  limited  strength. 

The  Respiratory  Movements  of  the  Stomach. 

The  diaphragm  rests  on  the  liver,  stomach  and  spleen  like  a  muscular 
dome,  hence  with  each  respiration  the  above  three  organs  (if  the  stomach  be 


Fig.  184.  Gastro-duodenal  dilatation — gastroptosia.  This  illustration  is  drawn  from 
the  subject.  This  subject  was  67  years  old,  dying  of  carcinoma  of  the  ductus  bilis  et  ductus 
pancreaticus.  It  is  a  so-called  transverse  stomach,  and  as  the  stomach  dilates  it  extends 
more  distalward  until  in  this  case  it  extended  to  the  pelvis.  Du  and  D  presents  the  enor- 
mously dilated  duodenum,  obstructed  by  the  superior  mesenteric  artery  A  and  vein  V. 
Observe  the  difference  in  dimension  between  the  duodenum  immediately  to  the  right  of  the 
mesenteric  vessels  and  that  immediately  to  the  left  of  them.  The  jejunum,  J.,  is  normal  in 
dimension,  while  the  duodenum  is  as  large  as  a  man's  arm.  A  segment  of  the  stomach 
and  duodenum  is  resected  at  D  to  show  the  dimension  of  the  distal  duodenum.  I,  a 
resected  segment  of  the  ventral  surface  of  the  duodenum  in  order  to  expose  Vater's 
papilla.  O,  elongated  oesophagus.  In  this  subject  the  pylorus  was  dilated  in  proportion 
to  the  duodenum  and  gastrium.  This  figure  is  from  the  same  subject  as  Fig.  185.  I  secured 
this  specimen  at  an  autopsy  by  the  professional  courtesy  of  Dr.  Charles  O'Byrne. 


578  THE  ABDOMLXAL   AND   PELVIC  BRAIX 

distended)  will  act  similarly — pass  distalward  according  to  the  resistance 
offered  by  the  muscles  of  the  abdominal  wall.  The  distended  stomach  will 
move  ventralward  at  each  inspiration.  The  stomach  exists  in  the  shape  of 
a  wedge  with  its  base  to  the  left.  The  liver  also  exists  in  the  shape  of  a 
wedge  with  its  base  to  the  right.  The  apex  of  the  liver  wedge  proximally 
overlaps  the  apex  of  the  stomach  wedge  distally.  At  every  inspiration  the 
apex  of  these  wedges  glide  on  each  other,  shortening  the  gastro-hepatic 
omentum,  while  at  each  expiration  the  gastro-hepatic  omentum  is  placed  on 
tension.  The  radix  mesenterica  or  root  of  the  mesentery  having  sent  one  of 
its  branches  to  the  liver — the  hepatic  artery — and  the  other  branch  to  the 
stomach — the  gastric  artery — it  remains  the  central  axis  around  which  the 
stomach  and  liver  rotate.  A  third  branch  of  the  radix  mesenterica — the 
splenic  artery — passes  to  the  spleen,  hence,  the  root  of  the  mesentery  is  the 
central  axis  of  the  visceral  rotation  (in  respiration)  of  the  liver,  stomach  and 
spleen.  Strong  fibrous  sheaths  of  connective  tissue  and  nerves  radiate  on 
the  hepatic,  gastric  and  splenic  arteries  to  their  respective  viscera  constitut- 
ing an  important  band  between  the  viscera  and  the  immobile  mesentery  root. 
The  ventral  elevation  of  the  epigastrium  at  each  inspiration  is  mainly  due  to: 
(a)  The  contraction  of  the  diaphragmatic  viscera  (liver,  stomach  and  spleen) 
distalward;  (b)  the  apices  of  the  liver  and  stomach  wedges  glide  on  each 
other  toward  their  bases  increasing  their  dorso-ventral  diameters.  The 
degree  of  elevation  of  the  epigastrium  at  each  inspiration  depends  on  the 
resistance  of  the  abdominal  wall  and  the  splanchnoptotic  state  of  the  dia- 
phragm and  of  the  subdiaphragmatic  viscera. 

Clinicians  may  observe  that  hepatic  calculus  is  more  frequent  in  splanch- 
noptosia  but  this  is  rationally  explained  by  the  facility  in  splanchnoptosia  of 
infectious  processes  invading  the  biliary  passages  from  lack  of  visceral  drain- 
age and  stasis  of  tissue  fluids — blood  and  lymph.  In  splanchonptotics  the 
ducts  are  flexed,  especially  the  biliary  ducts,  obstructing  the  normal  flow  of 
visceral  products.  Gastroptosia  is  practically  constantly  accompanied  by 
gastric  dilatation.  Gastric  dilatation  must  be  viewed  as  a  result  of  displace- 
ments and  not  a  cause.  In  gastroptosia  the  vessels  and  nerve  plexuses  are 
traumatized,  elongated,  which  impairs  gastric  innervation,  circulation  (lymph 
and  blood),  nourishment  and  a  muscularis  ending  in  dilatation. 

In  general  it  may  be  noted  that  the  coeliac  axis  (the  immobile  root  of  the 
mesentery  vessels  with  strong  fibrous  and  neural  sheaths)  is  a  secure  support 
to  the  liver,  stomach  and  spleen.  However,  the  visceral  shelves  of  the  sub- 
diaphragmatic organs  must  not  be  overlooked.  The  pancreas  (with  its 
corpus  securely  bound  to  the  immobile  coelac  axis  with  strong  fibrous  tissue) 
is  the  strongest  visceral  shelf  support.  The  next  strongest  visceral  shelf  is 
the  duodenum  which  in  the  adult  is  devoid  of  dorsal  epithelial  peritoneum 
but  the  strong  fibrous  subperitoneal  tissue  binds  the  whole  proximal  duodenum 
to  the  dorsal  wall  while  the  distal  duodenum  is  solidly  bound  to  the  cruva  of 
the  diaphragm  by  the  muscle  of  Treitz,  (musculus  suspensorius  duodeni)  and 
to  the  coliac  axis  by  strong  fibrous  tissue.  Hence  the  duodenum  and 
pancreas  (both  fixed  to  the  root  of    the  mesentery)  are  excellent    visceral 


SPLAKCHK0PT0S1A 


579 


shelves  for  liver,  stomach  and  spleen.  (Duodenum  and  pancreas  are  the  rara 
avis  in  hernia.)  When  the  splanchnoptosia  has  advanced  sufficiently  to 
involve  the  proximmal  duodenum  and  head  of  the  pancreas  the  duodenum  is 
liable  to  present  a  diverticulum  at    the  location  of  entrance  of    the    ducts 

choledochus  communis, 
while  the  pancreas  being 
fixed  in  its  middle  (corpus) 
will  locate  its  head  near 
sacral  promotory. 

Hepatoptosia  and  gas- 
troptosia  rest  chiefly  on  two 
causes,  viz:  (a)  relaxation  of 
the  abdominal  walls;  (b) 
constriction  of  the  trunk  by 
clothing.  In  both  (a)  and 
(b)  the  normal  respiration 
has  become  deranged. 

Gastroptosia. 


Gastroptosia  or  atonia 
gastrica  signifies  abdominal 
relaxation.  It  includes  dis- 
talward  movement  of  the 
stomach  and  relaxation  of 
the  abdominal  wall.  It  is  a 
part  and  parcel  of  splanch- 
noptosia. Gastroptosia 
(or  its  equivalent  atonia 
gastrica)  practically  includes 
the  terms  dilatation  of 
stomach,  ectasis  ventriculi, 
insufficiency  of  the  stomach, 
gastric  insufficiency,  motor 
insufficiency,  ischochymia 
(retention  of  chyme),  myas- 
thenia, extasis  gastrica, 
because  it  signifies  abdomi- 
nal relaxation  and  relaxa- 
tion includes  dilatation  and 
motor  insufficiency.  There- 
fore gastroptosia  is  a  proper, 
comprehensive,  scientific 
term  which  signifies  ptossi, 
dilatation  and  motor  insufficiency  of  the  stomach.  Gastroptosia  is  of  para- 
mount importance  to  physicians  as  its  existence  is  frequent  in  every  day 
practice. 


Fig.  185.  Carcinoma  completely  obstructing  the 
biliary  and  pancreatic  ducts.  From  same  subject  as 
Fig.  184.  Illustrates  an  X-ray  of  enormously  dilated  bil- 
iary passages.  The  biliary  ducts  (excepting  the  gall- 
bladder, which  was  three  to  four  times  its  normal 
dimension)  had  a  capacity  of  32  ounces,  about  six  or 
seven  times  the  natural  capacity.  The  ductus  communis 
choledochus  was  over  \l/\  inches  in  diameter.  The 
pancreatic  duct  admitted  the  index-finger.  The  man,  69 
years  old,  a  giant  in  stature,  weighing  some  250  pounds 
with  ordinary  limited  fat,  lost  115  pounds  in  weight  dur- 
ing three  months'  illness.  The  ductus  cysticus,  extend- 
ing from  II  to  IV,  had  seven  Heister's  valves,  and  its  lu- 
men would  admit  a  lead-pencil  only.  At  B  the  biliary 
ducts  were  deficient  within  the  liver  substance,  but  were 
really  dilated  on  the  surface.  T,  the  carcinoma  (divided 
with  the  scalpel),  completely  severing  the  lumen  of  the 
biliary  and  pancreatic  ducts.  There  was  enormous  gas- 
troduodenal  dilation  from  the  compression  of  the  trans- 
verse duodenum  by  the  superior  mesenteric  artery  (A) 
and  vein  (V).  D,  foldless,  granular,  proximal  2l/2 
inches  of  the  duodenal  mucosa;  1,  entrance  of  ductus 
communis  choledochus  in  the  duodenum ;  Sa,  ductus 
Santorini ;  P,  ductus  pancreaticus.  The  ductus  com- 
munis choledochus  and  ductus  pancreaticus,  located 
between  the  carcinoma  and  Vater's  diverticulum,  were 
normal.  Da  is  the  normal  sized  duodenum  located 
distal  to  the  compressing  superior  mesenteric  vein  (V) 
and  artery  (A).  Observe  the  vast  dilatation  of  the 
duodenum  proximal  to  the  superior  mesenteric  artery 
(A)  and  vein  (V).  I  secured  this  rare  specimen  at  an 
autopsy  through  the  courtesy  of  Dr.  Charles  O'Byrne. 


580 


THE  ABDOMLXAL   AXD   PELVIC  BRA  IX 


In  early  embryonic  life  the  stomach  is  absolutely  vertical  and  the  child 
is  practically  born  with  a  vertical  stomach  and  besides  I  have  observed 
scores  of  permanently  vertical  stomachs  in  adult  autopsies  (perhaps  from 
arrest  of  development).  With  the  growth  of  the  child  the  stomach  rotates 
following  the  atrophying  liver.  In  the  adult  the  rotated  stomach  is  supplied 
on  its  ventral  surface  (left)  by  the  left  vagus  and  on  the  c  surface  (right) 

by  the  right  vagus.  Food 
aids  by  its  weight  and  dis- 
tention to  force  the  stomach 
distalward.  In  gastroptosia 
the  lesser  curvature  and  py- 
lorus moves  distalward. 

Etiology. 

Gastroptosia  arises  from  a 
variety    of    causes.      Disor- 
dered  respiration  with  con- 
sequent   descensus    of     the 
diapnragm  and  distorted  dis- 
tal thorax  (ribs)  is  among  the 
first  disturbances.     In   short 
gastroptosia     coexists     with 
splanchnoptosia.         Gastro- 
ptosia may  be  due  to  an  ab- 
normally distalward  location 
of  the  diaphragm.     In  hepa- 
toptosia  the  liver  forces  the 
pylorus  distalward  and  to  the 
left.        Relaxed     abdominal 
walls,       rapidly        repeated 
pregnancies,    infected   puer- 
perium  i  i.  e.,  practically  sub- 
involution of  the  abdominal 
wall).       compression     from 
waist    bands,   liver  or  spleen 
tumors,  pleuritic  effusions  or 
adhesions,     pericarditis    are 
fruitful      causes    of    gastro- 
ptosia.    I  have  observed  in 
autopsies  that  peritoneal  and 
especially  omental  adhesions  play   an    extensive   role    in   gastroptosia. 

Gastroptosia  is  congenital  or  acquired.  The  acquired  gastroptosia  is 
discernible  in  the  change  in  normal  relations  of  the  space  in  the  proximal 
abdomen  and  distal  thorax  especially  in  the  manifestation  of  respiration.  In 
general  we  observe  at  post  mortems  two  forms  of  gastroptosia,  viz. :  (a)  the 
whole  stomach  appears  'with  the  lesser  curvature  and  pylorus  with  a  trans- 


Fig.  186.  This  illustration  presents  the  horizontal 
stomach,  which  in  gastroptosia  dilates  from  pylorus  to 
cardiac  extremity,  and  passes  distalward  as  in  Fig.  184— 
a  gastro-duodenal  dilatation.  Sig.  represents  the 
sigmoid  flexure  in  a  180  deg.  condition  of  phvsiologic 
vol  v.:. 


SPLANCHNOPTOSIA 


581 


verse  position)  moving  caudal,   (b)  the  distalward  moving  stomach  assumes 
more  or  less  a  distinctly  vertical  position. 

I  wish  to  state,  that,  from  personal  autopsic  observation  in  the  abdomi- 
nal  viscera   in  over  700  subjects,    the  stomach  varies    extensively:    (a)    in 

position,   (b)   in  dimension, 
(c)  in  form. 

Gastroptosia  may  be  due 
to  constitutional  defects  or 
anomalies  in  both  sexes. 
The  peculiar  formed  chest, 
as  funnel  shaped,  chicken 
breast,  may  be  observed  in 
subjects  with  gastroptosia 
which  is  part  and  parcel  of 
splanchnoptosia.  Gastro- 
ptosia occurs  in  subjects  with 
tubercular  habitus — consti- 
tutional defects. 

Gastroptosia  (or  splanch- 
noptosia) does  not  as  a  rule 
occur  in  strong  robust  sub- 
jects. Obvious  stigmata  of 
degeneracy  accompanying 
splanchnoptosia  subjects 
with  elongated  narrow  tho- 
rax are  liable  to  gastroptosia 
because  the  diaphragm  oc- 
cupies an  abnormally  distal- 
ward  location.  Pulmonary 
emphysemia  or  pleural  effu- 
sions force  the  diaphragm 
distalward  favoring  gastro- 
ptosia (and  concomitant 
splanchnoptosia).  Mechan- 
ical conditions  may  enhance 
stomachoptosia  as  supraum- 
bilical  hernia,  inguinal  or 
femoral  hernia,  peritoneal 
adhesions.  Rapidly  repeated 
gestations  present  a  large 
field  of  gastroptosia  so  fully 
discussed  by  Landau  as  well  as  rapid  loss  of  large  quantities  of  fat.  In  multi- 
para and  subjects  with  loss  of  quantities  of  flesh  the  abdominal  muscles 
become  relaxed  and  lose  their  delicate  active  poise  in  maintaining  the  vis- 
cera in  their  normal  physiologic  position. 


Fig.  187.  This  represents  a  vertical  stomach.  Dur- 
ing gastro-duodenal  gastroptosia  the  chief  gastric  dilata- 
tion occurs  at  the  distal  end  of  the  stomach.  The 
superior  mesenteric,  S,  compressing  the  transverse 
duodenum,  causes  the  gastro-duodenal  dilatation.  This 
figure  presents  a  non-descended  cecum,  and  an  ileum, 
I,  adherent  to  the  ileopsoas  muscle.  1,  2,  4  represent- 
ing the  dorsal  insertion  line  of  the  meso-sigmoid. 


>82 


THE  ABDOMINAL  AND  PELVIC  BRAIN 


Gastric  Dilatation  in  Splanchnoptosia. 

Many  times  I  have  observed  in  autopsy  extensively  dilated  stomach,  the 
existence  of  which  in  life  had  not  been  suspected,  first,  because  the  physical 
condition  of  the  patient  was  favorable  and  second  compensatory  action 
between  stomach  and  pylorus  was  still  favorable.  A  relation  exists  between 
the  dimensions  of  the  pylorus  and  that  of  the  stomach — a  compensatory 
action.  I  performed  an  operation  on  a  woman  who  had  vomited  for  years 
with  a  dilated  stomach.  In  this  case  the  pylorus  had  dilated  slightly  and  its 
flexion  increasing  by  ptosis 
obstructed  the  free  evacua- 
tions of  the  stomach  con- 
tents. 

Again  we  note  autopsies  in 
which  a  subject  possesses  a 
markedly  dilated  stomach 
with  slight  difficulty  in 
evacuation  of  stomach  con- 
tents through  the  pylorus 
because  the  pyloric  ring  had 
dilated  proportionately  with 
the  stomach  dilatation  allow- 
ing free  evacuation,  free 
passage  of  food  from 
stomach  to  duodenum,  free 
drainage — here  is  compen 
satory  dilatation- of  stomach 
and  pylorus,  resembling  that 
of  the  cardiac  valves,  how- 
ever, suddenly  the  stomach 
and  pyloric  compensatory 
action  may  fail  and  the 
patient  passes  swiftly  on- 
ward and  swiftly  downward 
— exactly  as  ''a  valvular 
heart  lesions. 

The  etiology  of  gastro- 
ptosia  may  be  sought  chiefly 

in  constitutional  defects.  However,  mechanical  derangement  is  sufficiently 
obvious  in  gastroptosia.  Gastro-duodenal  dilatation  which  plays  such  an  ex- 
tensive role  in  splanchnoptosia  will  be  discussed  and  illustrated  in  a  future 
chapter.  Combined  gastro-duodenal  dilatation  due  to  the  compression  of 
the  transverse  duodenal  segment  by  the  superior  mesenteric  artery  vein 
and  nerve  is  a  frequent  condition  and  though  I  have  published  articles  on  it 
for  a  decade  it  is  still  but  limitedly  recognized. 

The  symtomatology  may  be  practically  negative  or  of  the  most  aggra- 


Fig.  188.  illustrates  gastroptosia.  The  colon 
transversum  forced  distalward  into  the  pelvis  by  the 
stomach.  1,  liver  with  hepatoptosia ;  2,  stomach  in  the 
lesser  pelvis;  3,  4,  duodenum  dilated;  5,  the  jejunum, 
normal  caliber;  6,  transverse  colon.  This  cut  repre- 
sents gastro-duodenal  dilation — the  second  stage  of 
splanchnoptosis. 

The  artist  neglected  to  present  the  duodenum 
dilated. 


SPLANCHNOPTOSIA  583 

vated  kind.  It  may  be  stated,  in  general,  that  gastroptosia  is  without 
symptoms  so  long  as  the  stomach  functionates  normally  which  mainly 
prevails  while  the  subject  is  in  favorable  physical  condition.  Gastroptosia 
presents  symptoms  when  detention  and  composition  food  occurs  and  general 
infection  results.  Indirect  symptoms  may  arise  as  in  splanchnoptosia,  e.  g., 
fatigue,  debility,  constipation,  insomnia.  Meinert  insist  that  gastroptosia  is 
a  common  cause  of  chlorosis. 

The  symptoms  of  gastroptosia  are  generally  proportionate  to  the  degree 
of  stomachic  dilatation.  Kussmaul  originally  observed  that  gastroptosia  is 
frequently  accompanied  by  a  disturbance  of  the  motor  nerves  of  the  stomach. 
This  may  be  due  to  the  trauma  traction  on  the  vagi  from  change  of  gastric 
position.  Gastroptosia  frequently  coexists  with  multiple  nervous  symptoms, 
but  the  nervous  symptoms  may  be  due  to  splanchnoptosia.  However,  gas- 
troptosia is  a  disease  and  is  liable  to  be  accompanied  by  disturbed  motion, 
absorption,  secretion  and  sensibility  of  the  stomach.  Change  of  form  and 
position  of  the  stomach  may  not  lead  to  any  more  nervous  symptoms  than 
change  of  form  and  position  of  the  uterus,  however  dislocation  of  the  uterus, 
i.  e.,  permanent  fixation,  is  the  result  of  some  disease. 

Malposition  of  the  stomach  does  not  produce  neurasthenia  any  more 
than  malposition  of  the  uterus.  The  position  of  a  mobile  viscus  is  not 
responsible  for  neurosis,  for  mulitple  positions  or  multiple  deviations  must 
not  be  considered  abnormalities.  It  is  disease  that  produces  neurosis,  not 
position  of  viscera.  Original  disease  which  produced  the  malposition  of  the 
viscus  should  be  held  responsible  for  the  nervous  disturbance.  Again  there 
can  be  no  doubt  that  the  symptoms  of  gastroptosia  and  nephroptosia  are 
constantly  mistaken  for  each  other  especially  by  the  careless  examining  sur- 
geon with  a  tendency  to  nephropexy.  There  is  no  characteristic  stomach 
contents  peculiar  to  gastroptosia.  In  gastroptosia  pain  is  generally  prevalent 
in  the  proximal  abdomen  and  lumbar  regions.  It  is  true  that  subjects  with 
gastroptosia  (a  part  and  parcel  of  splanchnoptosia)  present  multiple  neurotic 
symptoms  simulating  disturbed  mobility,  secretion,  absorption  and  sensibility 
of  the  stomach.  However,  this  may  belong  in  the  congenital  debility  or 
predisposition  of  the  patient — due  to  the  disturbance  created  by  anatomically 
dislocated  viscera  and  consequently  pathologic  physiology.  Gastroptosia 
increases  the  weight  of  the  stomach. 

Diagnosis. 

Gastroptosia  is  less  recognized  than  nephroptosia  which  is  diagnosed 
with  more  facility  and  besides  the  pexyites  are  more  vigorously  in  search  of 
nephroptotic  victims. 

Percussion  and  auscultation  with  various  quantities  of  fluid  in  the 
stomach  may  suggest  the  position  and  dimension  of  the  stomach. 

Palpable  epigastric  pulsation,  absence  of  projecting  abdominal  wall  in 
the  epigastrium  and  projecting  abdominal  walls  in  the  hypogastrium  aid  in 
the  diagnosing  gastroptosia. 

The  most  exact  method  to  determine  the  position  and  dimension  of  the 


584  THE  ABDOMIXAL   AXD   PELVIC  BRA  IX 

stomach  is  by  inflation,  viz. :  (a)  by  generation  of  gas  within  the  stomach. 
The  most  frequent  method  of  gastric  inflation  practiced  is  by  directing  the 
patient  to  drink  a  glass  of  water  containing  some  sodium  bicarbonate  and 
immediately  to  drink  another  glass  of  water  containing  tartaric  acid  whence 
carbonic  acid  gas  is  formed  distending  the  stomach  by  air.  (b)  Another 
method  to  inflate  the  stomach  is  by  introducing  into  the  stomach  a  tube 
whence  air  is  forced  through  it  for  distention,  whence  its  form,  position  and 
dimension  may  be  observed  through  the  abdominal  wall,  (c)  A  third  method 
of  diagnosing  the  form,  position  and  dimension  of  the  stomach  is  by  distend- 
ing the  stomach  by  fluid. 

When  the  major  curvature  is  at  or  below  the  umbilicus  and  the  pylorus 
and  lesser  curvature  have  moved  distalward  the  diagnosis  of  gastroptosia  is 
confirmed.  A  healthy  stomach  maintains  the  position  of  its  borders  regard- 
less of  the  subject's  attitude.  In  gastroptosia  the  borders  of  the  stomach 
change  according  to  the  patient's  position.  In  gastroptosia  with  the  patient 
in  the  erect  posture  the  major  stomach  curvature  and  pylorus  will  be  more 
caudal,  while  if  the  patient's  posture  is  recumbent  the  pylorus  and  major 
curvature  cephalad.  Succussion  (splashing  sound)  is  a  method  to  diagnose 
gastroptosia  by  agitating  air  and  water  in  the  stomach  through  shaking  the 
body.  The  splashing  sound  may  also  be  obtained  by  palpating  the  stomach 
while  the  patient  is  in  the  recumbent  position.  A  splashing  sound  elicited 
from  the  stomach  means  practically  gastroptosia — relaxation,  atony.  Some 
persons  by  practicing  pressure  of  the  abdominal  muscles  of  the  stomach  can 
produce  various  sounds  in  the  stomach.  Such  persons  perhaps  possess 
abnormally  a  large  stomach  and  powerful  abdominal  muscles,  however,  like 
a  fakir  have  exaggerated  an  anomaly.  Gastroptosia  may  be  diagnosed  by 
transillumination,  i.  e..  introducing  an  electric  light  in  the  stomach  whence 
its  contour  may  be  observed.  This  method  was  advocated  in  1845  by  Case- 
nave,  later  in  1867  Milliot  improved  it  by  experimentation,  however,  Dr. 
Max  Einhorn  of  New  York  practically  first  made  successful  use  of  (the  gastro- 
diaphane)  transillumination  of  the  stomach  in  man  and  demonstrated  the 
utility  of  gastro-diaphanes  copy. 

Inspection  may  present  a  depression  in  the  epigastrium  and  a  projection 
in  the  umbilical  region.  This  method  of  diagnosis  may  be  sufficient  in  spare 
persons  to  announce  gastroptosia.  The  X-ray  may  be  used  to  note  the  posi- 
tion of  the  stomach  by  administering  substances  which  will  cast  a  shadow, 
as  subnitrate  of  bismuth  or  metallic  salts  administered  in  capsules.  Treat- 
ment is  medical,  mechanical,  surgical. 

Treatment. 

1.  The  medical  treatment  consists  in  regulation  of  diet  and  function. 
The  dietetic  management  consists  in  administering  limited  quantities  of 
prescribed  food  at  regular  three-hour  intervals.  The  diet  should  be  cereals, 
vegetables,  milk  and  eggs.  All  high  seasoned  food,  pastry,  pie,  cake,  spices, 
meat  should  be  excluded  to  avoid  fermentation. 

The  most  essential  medical  treatment  consists  in  "visceral  drainage"  as 


SPLANCHNOPTOSIA 


585 


ample  sewerage  the  evacuating  channels  should  be  flushed.  Gastroptotics 
may  live  healthy  with  ample  visceral  drainage.  The  tissues  and  tissue 
spaces  in  gastroptosia  (splanchnoptosia)  require  flooding,  washing,  so  that 
the  subject  may  be  free  from  waste  laden  blood  and  residual  debris.  Every 
evacuating  visceral  tract  (tractus  intestinalis,  perspiratorius,  urinarius  res- 
piratorious)  should  perform  maximum  duty.  The  sheet  anchor  treatment  for 
gastroptosia  is  regulation  of  food  and  fluid,  and  maximum  sewerage  of 
visceral  tracts.  Dietetics,  hygiene,  anatomic  and  physiologic  rest,  properly 
supervised,  tend  extensively  to  the  welfare  in  the  life  of  a  splanchnoptotic. 

2.  Mechanical  treat- 
ment in  gastroptosia  judic- 
iously applied  affords  won- 
derful relief.  Stomachic 
irrigation  occasionally  ren- 
ders much  comfort.  The 
treatment  consists  in  the  ap- 
plication of  abdominal  wall 
to  support  the  viscera.  This 
is  accomplished  by  various 
kinds  of  abdominal  binders 
— elastic  and  non-elastic.  I 
use  sometimes  an  abdominal 
binder  within  which  is  placed 
a  pneumatic  rubber  pad 
which  is  distended  with  air 
to  suit  the  patient's  comfort. 
Dr.  E.  A.  Gallant  employs 
a  suitable  fitting  corset. 
The  adhesive  strapping 
method  of  Achilles  Rose  is 
practical,  rational  and 
economical  and  affords  ex- 
cellent relief.  The  recum- 
bent position  aids  the  patient. 
The  mechanical  method  at- 
tempts the  forcible  reposi- 
tion of  the  stomach  to  its  normal  physicologic  position  and  there  to  main- 
tain it  by  aids  applied  to  the  abdominal  wall — a  rational  method.  Preg- 
nancy practically  relieves  the  gastroptosia  for  a  season.  Splanchnoptotics 
experience  more  comfort  from  rational  adhesive  strapping  (mechanical  sup- 
ports) than  from  surgical  procedures. 

3.  Surgical  treatment  in  gastroptosia  is  a  very  limited  field.  It  espouses 
two  methods,  viz. :  (a)  The  surgery  is  applied  to  the  stomach  itself  as  gas- 
troenterostomy, the  Heinicke-Mickulicz  operation  (both  tend  to  cure  by 
visceral  drainage)  the  replication  of  the  stomach  parietes  or  the  attempt  to 
shelve  the  stomach  by  omentum  or  mesentery  (both  unphysiclogic,  irrational). 


Fig.  189  illustrates  the  third  stage  of  splanch- 
noptosia, viz. :  gastro-duodenal  dilatation.  It  shows  the 
transverse  colon  (5)  in  the  lesser  pelvis.  The  widely 
dilated  stomach  (1)  is  drawn  leftward  by  hooks  (10) 
from  its  bed  to  show  the  duodenum  (2)  dilated  by  the 
superior  mesenteric  artery,  vein  and  nerve,  (3)  4,  the 
normal  calibered  loops  of  enteron  ;  6,  right  colon  ;  7, 
cecum ;  8,  the  appendix.  Note  the  enteron  loops 
crowded  into  the  lesser  pelvis. 


THE   ABDOMIXAL   AXD   PELJ'IC   BRAIX 

(b)  The  abdominal  wall  is  employed  to  support  the  stomach  as  by  incision 
and  over-lapping  like  a  double  breasted  coat,  or  by  enclosing,  uniting  the 
two  musculi  recti  abdominales  in  one  sheath.  Both  methods  attempt  to 
relieve  by  lessening  the  abdominal  cavity  and  forcing  the  stomach  into  its 
normal  physiologic  position  ('both  rational").  A  third  method  is  to  perform 
gastropexy.  i.  e.,  suture  the  stomach  to  the  abdominal  wall  (limited,  irrational 
in  generalj. 

HEPATOPTOSIA,   COLOPTOSIA  AND  ENTEROPTOSIA  IN  SPLAXCHXOPTOSIA. 

Fixation  of  the  Livt  • 

The  liver  is  firmly  fixed  to  the  diaphragm  only.  It  has  the  most  exten- 
sive fixation  to  the  diaphragm  of  any  abdominal'  viscus,  hence  the  action  of 
the  diaphragm  in  respiration  will  be  the  most  comprehensive.  The  structures 
which  maintain  the  liver  in  contact  with  the  concavity  of  the  diaphragm  are: 
a)  peritoneal  folds;  (b)  connective  tissue :  (c)  vessels;  (d)  abdominal  mus- 
cles (most  important;.  The  liver  rests  on  a  visceral  shelf,  composed  of  the 
stomach,  duodenum,  right  kidney,  pancreas  and  transverse  colon.  The  vena 
cava  and  hepatic  veins  by  their  intimate  fusion  with  both  liver  substance  and 
the  diaphragm  constitute  a  strong  bond  of  union.  The  dorsal  mesentery  of 
the  liver — the  mesepaticon  meso-hepor — is  constituted  by  the  extensive  con- 
nective tissue  which  binds  the  right  lobe  of  the  liver  to  the  distal  concave 
surface  of  the  diaphragm  together  with  the  reflexion  of  peritoneum  which 
surrounds  the  connective  tissue  area. 

The  mesepaticon  forms  the  most  important  passive  band  of  the  liver  and 
diaphragm.  The  right  and  left  lateral  ligaments  are  mere  extensions  of  the 
mesepaticon.  The  suspensory  ligament,  the  remnant  of  the  ventral  hepatic 
mesentery,  is  long  and  loose  to  allow  respiratory  movements.  An  excellent 
example  of  what  the  respiratory  movements  of  viscera  may  accomplish  is 
observed  in  the  bursa  of  Spiegel.  Spiegel's  lobe  moves  proximalward  and 
iistaiward  with  each  respiration  and  by  this  continual  action  has  formed  a 
diverticulum  in  the  lesser  sac  of  the  peritoneum — Bursa  spigelii.  The 
proximalward  and  distalward  movements  of  Spiegel's  lobe  produced  by  the 
diaphragm  in  respiration  is  responsible  for  Spiegel's  diverticulum  in  the  peri- 
toneum. 

Respiratory  Movements  of  the  Liz-cr. 

If  one  studies  the  diaphragm  it  will  be  observed  that  its  muscular  con- 
tractions tend  toward  the  radix  mesenterica.  When  the  diaphragm  contracts 
(inspiration)  on  the  broad  dorso-^rcximal  dome-like  hepatic  surface  it  will 
force  the  liver  distalward,  %  r.:ralward  and  medianward.  At  every  inspira- 
tion the  liver  pounds  en  the  abdminal  viscera  distal  to  it  like  a  hammer, 
especially  in  thorazic  splanchnoptosia.  The  degree  of  distalward  movements 
the  liver  in  inspiration  depends  on  the  resistance  offered  by  the  muscles  of 
the  abdominal  wall.  These  movements  of  the  liver  in  inspiration  imposed 
on  it  by  the  diaphragm  do  not  disturb  its  function,  on  the  contrary  doubtless 
aid  in  massaging  the  liver  into  vigorous  function. 


SPLANCHNOPTOSIA 

The  normal  respiratory  movements  of  the  liver  may  become  disturbed 
by  relaxation  of  the  diaphragm  or  abdominal  walls  which  rob  it  of  normal 
support.  Tight  lacing  may  force  the  liver  from  its  visceral  niche  and  shelf 
whence  the  normal  inspiratory  muscular  action  becomes  ungeared.  Peri- 
hepatic peritoneal  or  pleuritic  adhesions  particularly  distort  respiratory 
muscular  actions  on  the  liver  and  consequent  normal  function.  Hepato- 
Ptosia  is  not  a  rare  condition,  especially  when  the  liver  has  lost  its  visceral 
shelf  and  the  abdominal  walls  become  relaxed. 

Etiology  of  Hepato-Ptosia. 

Hepato-Ptosia  is  a  part  and  parcel  of  splanchnoptosia  and  depends  on 
the  same  causes — as  deranged  respirations,  relaxed  abdominal  walls,  yielding 
of  the  diaphragm,  hepatic  ligaments  and  visceral  shelves  (kidney,  duodenum 
transverse  colon,  pancreas,  stomach)  peritoneal  and  omental  adhesions, 
plueritic  effusions  and  exudates  asthma,  rapidly  repeated  pregnancies,  heredi- 
tary or  congenital  debilities,  persistent  vomiting  and  coughing,  hernia, 
tight  waist  band,  corsets,  trauma,  congenital  predisposition. 

The  elongation  of  the  hepatic  ligaments  are  secondary  to  the  relaxation 
of  the  abdominal  wall.  Further  etiologic  factors  in  hepato-ptosia  are  the 
weight  of  the  liver,  cholelithiasis,  weight  of  the  gall-bladder,  laxity  or  elon- 
gation of  the  hepatic  ligaments  (which  are  probably  secondary  to  the  relaxa- 
tion of  the  abdominal  wall),  trauma  as  during  parturition,  disappearance 
of  the  visceral  shelves.  The  chief  immediate  course  of  hepato-ptosia  is 
relaxation  of  the  ventral  abdominal  wall.  The  liver  like  the  uterus  rests  on 
a  floor  or  visceral  shelf. 

Frequency. 

Hepato-Ptosia  occurs  the  most  frequently  in  women.  During  the  past 
15  years  I  have  observed  about  one  typical  advanced  clinical  case  a  year; 
however,  numerous  subjects  may  be  observed  with  a  moderate  degree  of 
hepato-ptosia,  especially  those  having  a  tendency  to  develop  Riedel's  lobe. 
The  frequency  of  hepato-ptosia  is  concomitant  with  splanchnoptosia,  which 
is  a  common  ailment.  Perhaps  seven  women  suffer  from  hepato-ptosia  to 
one  man.  I  have  examined  subjects  of  extreme  hepato-ptosia  in  whom  I 
could  palpate  the  liver  per  vaginum.  The  history  of  hepato-ptosia  is  recent, 
as  Portal  was  among  the  first  to  call  attention  to  it  in  autopsy  (1304)  and  the 
first  case  described  in  the  living  was  by  Cantani  in  1866.  Autopsies  revealed 
its  condition  previous  to    that,   but  its    interpretation    remained    unsolved. 

The  liver  lies  in  an  excavation  in  the  concavity  of  the  diaphragm  resting 
on  a  visceral  shelf.  Its  primary  maintainers  are  the  power  of  the  abdominal 
wall.  Its  secondary  maintainers  are  the  suspensory,  coronary,  triangular, 
ligaments  and  mes-hepaticon,  mesohepar.  The  elongation  of  these  five  sup- 
ports allows  distalvvard  movements  of  the  liver.  Floating  liver  is  intimately 
associated  with  splanchnoptosia— is  part  and  parcel  of  it — for  in  autopsy  it 
is  common  to  note  the  kidney,  hepatic  flexure,  enteron  passing  distalward 
before  the  liver.     I  have  personally  examined  in  the  living  and  dead  about  a 


588  THE  ABDOMLXAL   AXD   PELVIC   BRAIX 

dozen  typical,  advanced,  so  called  Riedel's  lobes.  In  every  subject  of 
marked  Riedel's  lobe  splanchnoptosia  was  marked.  The  vast  majority  of  the 
subjects  were  women. 

First,  when  the  right  liver  lobe  becomes  forced  excessively  distalward 
the  costal  margin  tends  to  separate  the  proximal  form  the  distal  part  of  the 
lobe  by  compressing  a  crease  in  the  liver.  The  distal  part  of  the  right  lobe 
which  is  extended  distal  to  the  costal  margin  becomes  an  increasing  Reidel's 
lobe.  Second,  the  space  between  the  distal  costal  margin  and  the  proximal 
crest  of  the  ilium  allows  Riedel's  lobe  to  develop,  as  here  the  abdominal 
walls  offer  the  direction  of  least  resistance. 

Symptomatology. 

The  symptoms  of  hepato-ptosia  are  acute  or  chronic,  partial  or  complete. 
In  general  the  clinical  symptoms  are  dragging  pain  in  the  abdomen,  nausea, 
vomiting,  dizziness,  constipation  alternating  with  diarrhcea,  ascites,  a  peculiar 
rhythmic  distressing  "hepatic"  cough  with  numerous  neurotic  disturbances 
and  malassimilation.  Curiously  enough  one  not  infrequently  meets  a  subject 
with  hepato-ptosia  presenting  no  objective  symptoms. 

Diagnosis. 

The  diagnosis  rests  on  bimanual  palpation,  percussion,  a  mobile  mass  in 
right  side,  change  in  location  of  tumor  by  change  of  attitude.  Liver  dullness 
changes  with  different  positions  and  the  liver  may  be  felt  in  each  different 
position.  The  liver  in  hepato-ptosia  may  assume  any  position  in  the  abdom- 
inal cavity.  If  the  kidney  is  not  enlarged  nephroptosia  can  be  differentiated 
from  hepato-ptosia;  however,  with  enlarged  kidney  it  may  be  impossible.  I 
have  examined  subjects  with  the  best  of  experts  in  urology,  where  it  was 
impossible  to  decide  until  peritonotomy  was  executed. 

An  excellent  factor  in  diagnosis  is  to  attempt  to  replace  the  liver  with 
the  patient  recumbent,  which  if  successful  is  confirmatory  of  hepato-ptosia; 
examine  the  liver  in  the  erect  and  prone  position.  As  the  liver  passes  distal- 
ward  it  is  liable  to  rotate  to  the  right  on  the  ligamentum  umbilicale  as  an 
axis.  A  warning  is  offered  that  Riedel's  lobe  should  be  differentiated  from 
hepato-ptosia.  Riedel's  lobe  is  a  direct  extension  distalward  of  the  distal 
portion  of  the  right  hepatic  lobe.  Its  etiology,  though  obscure,  appears  to 
be  associated  with  diseases  of  the  gall-bladder,  cholelithiasis  or  tight  waist 
bands. 

The  development  of  Riedel's  lobe  appears  to  be  intimately  connected 
with  cholelithiasis;  however,  I  have  seen  Riedel's  lobe  sufficiently  frequent 
in  both  the  living  and  the  dead  with  no  cholelithiasis  present,  to  know  it  is. 
not  the  only  cause. 

Occasionally  we  can  diagnose  floating  liver  of  considerable  degree 
accompanied  apparently  by  no  symptoms.  I  have  observed  subjects  of 
hepato-ptosia  when  a  distinct  bulging  presented  in  the  distal  right  quadrant 
of  the  abdomen  with  no  symptoms. 

In  hepato-ptosia  the  liver    rotates  on  its    pedicle  (transverseaxis),    the 


SPLANCHNOPTOSIA 


589 


torsion  of  which  compromises  its  anatomy  and  physiology  (biliary  ducts, 
Porta)  vein,  hepatic  artery,  lymphatics  and  nerves).  With  change  of  position 
(hepato-ptosia)  the  liver  experiences  change  of  form.  Hepato-ptosia  does 
not  occur  without  dislocation  and  change  of  adjacent  organs.  In  hepato- 
ptosia  the  change  in  form  and 
position  of  the  liver  is  not  due 
merely  to  pressure  of  the  abdomi- 
nal wall  (muscle  or  bony)  but  to 
the  necessity  of  physiologic  move- 
ment as  liver  rhythm  and  applica- 
tion of  adjacent  viscera  against 
the  liver  by  respiratory  move- 
ments. The  liver  is  dislocated 
through  disease,  i.  e.,  by  patho- 
logic physiology  or  pathologic 
anatomy  of  adjacent  viscera  or 
body    walls. 

Treatment. 

The  treatment  is:  1,  Medical, 
such  as  diet,  "visceral  drainage," 
stimulation  of  the  functions  of  the 
visceral  tracts  to  a  maximum 
degree  of  elimination  by  injesting 
liberal  quantities  of  fluids  at 
regular  intervals,  ample  horizon- 
tal rests.  Forced  nutrition  aids 
in  restoring  the  fat  cushions.  The 
patient  must  avoid  excessive  or 
traumatic  exertions.  2,  Mechan- 
ical treatment  consists  in  forcible 
reposition  and  maintaining  the 
liver  in  its  normal  physiologic 
position.  Apply  abdominal  bin- 
ders, adhesive  strapping  or  an 
applicable,  suitable  corset  (Galla- 
net).  The  mechanical  methods 
afford  wonderful  relief,  especially 
Achilles  Rose'smethod of  adhesive 
strapping.  3,  Surgical.  Hepato- 
pexy  should  be  performed  only  as 
a  last  resort.  It  has  an  extremely 
performed  over  50  times  since  its 
Overlapping  the  abdominal  walls 
tional  and  secures  more  successful 
ish  the  abdominal  cavity  and  force 
tion  in  the  diaphragmatic   concavi 


Fig.  190.  Coloptosia.  The  transverse  colon 
extends  into  the  lesser  pelvis.  Coloptosia 
increases  the  flexion  of  the  flexura  hepatica  coli 
and  the  flexura  linealis  coli,  increasing  the  diffi- 
culty and  friction  of  fecal  circulation.  Z  The 
cupola  of  the  sigmoid,  presenting  a  physiological 
sigmoid  volvulus.  CO  Coecum  located  in  the 
lesser  pelvis,  with  the  appendix  Ap.  II.  Ileum, 
coursing  proximalward  and  parallel  with  the  right 
colon,  assuming  conditions  favorable  to  an  ileo- 
cecal volvulus.  X  illustrates  that  during  volvulus 
of  the  sigmoid  it  appropriates  peritoneum,  and 
formulates  it  into  an  additional  elongated  meso- 
sigmoid. 


limited  field  of  usefulness.  It  has  been 
introduction  in  1877  with  doubtful  results, 
like  a  double  breasted  coat  is  more  ra- 
results,  as  such  a  procedure  would  dimin- 
the  liver  in  its  normal  dome-like  excava- 
ty  and  on  its  normal  visceral  shelf. 


590  THE  ABDOMINAL   AND   PELVIC   BRAIN 

Coloptosia. 

The  colon  has  received  some  attention  in  splanchnoptosia  from  its  rela- 
tion to  nephroptosia  and  hepato-ptosia  gastroptosia  :  (a)  Coloptosia  transversa. 

The  dislocation  of  the  middle  of  the  transverse  colon  producing  more  or 
less  of  a  curve  with  its  concavity  proximalward,  is  one  of  the  most  frequent 
factors  in  splanchnoptosia.  Dislocation  of  the  colon  is  placed  in  relation 
with  the  relaxed  abdominal  wall  with  elongation  of  the  mesocolon  with  con- 
stipation, with  tight  waist  bands,  with  gastroptosia,  nephroptosia,  hepato- 
ptosia;  however,  no  one  theory  is  satisfactory. 

It  is  true  that  by  circular  constriction  of  the  abdomen  one  can  force 
some  viscera  proximalward  and  many  distalward.  However,  at  autopsy  I 
found  even  in  youth,  in  nullipara  in  absence  of  corset,  that  the  colon  trans- 
versum  may  be  located  well  distalward  from  the  umbilicus.  We  can  observe 
that  not  only  the  mesocolon  transversum  was  elongated  but  also  the  ligamen- 
tum  gastro-colicum,  i.  e.,  the  visceral  mesenteries  were  elongated.  With 
the  elongated  mesocolon  transversum  the  transverse  colon  can  assume  vari- 
ous positions. 

In  autopsy  it  is  common  to  observe  the  middle  of  the  transverse  colon 
projection  into  the  pelvis  and  not  frequently  the  colon  may  lie  in  the  lesser 
pelvis  and  on  its  floor.  The  middle  loop  of  the  transverse  colon  can  be 
moved  with  facility  to  any  portion  of  the  peritoneal  cavity.  The  enteronic 
loops  may  glide  proximalward  ventral  to  the  transverse  colon.  The  right 
portion  of  the  transverse  colon  is  frequently  prevented  from  distalward 
movements  by  reason  of  pathologic  peritoneal  adhesions  binding  it  to  the 
liver.  The  mesocolon  transversum  measures  generally  4>^  inches;  however, 
in  subjects  of  coloptosia,  I  have  observed  it  nine  inches  in  length  and  fre- 
quently six  inches.  The  membrana  mesenterii  propria,  i.  e.,  the  submesocolic 
tissue,  vessels  and  nerves,  are  elongated,  attenuated.  Coloptosia  trans- 
versum plays  a  prominent  role  in  autopsic  observations. 

Hepato-ptosia  and  nephroptosia  may  be  advanced  sufficiently  to  force 
the  colonic  hepatic  flexure  so  far  distalward  that  it  becomes  reversed.  In 
such  cases  the  colon  extends  from  the  coecum  obliquely  across  the  abdomen 
to  the  spleen.  The  clinical  hisotory  of  such  patients  was  mostly  unknown. 
However,  I  am  not  convinced  that  these  marked  dislocations  of  the  right 
and  transverse  colon  manifested  grave  symptoms.  For  the  transverse  colon 
in  general  will  measure  about  22  inches,  and  since  the  abdominal  cavity 
between  the  points  of  the  splenic  and  hepatic  flexures  is  some  14  inches  the 
transverse  colon  must  assume  a  sinuous  or  looped  course  of  more  or  less 
deviation  from  an  extended  line. 

Coloptosia  Dextra. 

The  right  colon  becomes  of  significant  interest  in  coloptosia  on  account 
of  its  relation  to  nephroptosia  and  hepato-ptosia,  the  appendix  and  tractus 
genitalis  as  well  as  to  the  fact  that  the  colon  dextrum  not  infrequently  pos- 
sesses a  mesocolon.  The  resistance  to  coloptosia  dextra  is  chiefly  offered  by 
the  ligamentum  costo-colicum  dextrum,  which  vigorously  fixes  the  cecum,  in 


SPLANCHNOPTOSIA  501 

many  subjects,  checks  its  distalward  movements,  preventing  it  from  becoming 
a  resident  in  the  lesser  pelvis  (woman  20%,  man  10$  ). 

The  base  or  root  of  the  right  mesocolon  is  fixed  to  the  ventral  surface  of 
the  distal  renal  pole,  hence  maintains  intimate  relations  to  nephroptosia 
dextrum.  The  right  colon  is  about  eight  inches  plus  two  inches  for  the 
cecum,  assumes  a  sinuous  or  looped  course  in  most  bodies  and  the  additional 
loops  of  moderate  coloptosia  dextra  perhaps  produce  few  symptoms. 

Coloptosia  Sinistra. 

The  left  colon  is  so  infrequently  dislocated  from  the  fact  that  it  is  rarely 
possessing  a  mesocolon  that  I  omit  its  discussion  in  coloptosia. 

Coloptosia  Sigmoidea, 

It  is  difficult  to  define  splanchnoptosia  of  the  sigmoid,  as  it  has  an  exten- 
sive normal  range  of  mobility.  In  general  it  is  17  inches  in  length  in  woman 
and  19  in  man.  Its  mesosigmoid  will  average  V/2  inches.  The  base  of  the 
mesosigmoid  insertion — its  foot — is  but  a  few  inches  in  length  and  hence  the 
sigmoid  will  move  about  freely  in  the  peritoneal  cavity.  In  autopsies  the 
sigmoid  may  be  found  the  most  frequently  in  the  lesser  pelvis  (65%  to75%), 
in  the  right  iliac  fossa  (15%),  in  the  proximal  abdomen  (15%).  It  may  be 
in  contact  with  the  spleen,  stomach,  liver  or  cecum.  The  most  distinct 
reason  for  the  nonsplanchnoptotic  state  of  the  sigmoid  is  that  the  trauma  of 
the  psoas  produces  more  or  less  plastic  peritonitis  in  the  mesosigmoid  (meso- 
sigmoiditis)  in  80%  of  subjects  and  the  mesosigmoiditis  contracts  the  meso- 
sigmoid, fixing  it  to  the  Psoas  muscle,  preventing  coloptosia  sigmoidea.  It 
is  claimed  that  in  coloptosia  of  the  sigmoid  that  it  forms  dangerous  obstruct- 
ing angulation  which  is  yet  to  prove. 

Symptomatology. 

The  symptoms  of  coloptosia  include  many  due  to  general  splanchnop- 
tosia. Some  of  the  symptoms  are  (a)  constipation;  (b)  diarrhoea — (a)  and 
(b)  alternating — (c)  colonic  catarrh,  mucous  colitis  or  which  I  prefer  to  term 
secretion  neurosis  of  the  colon.  The  colonic  secretion,  absorption,  sensa- 
tions, and  peristalsis  may  be  excessive,  deficient  or  disproportionate. 
Fermentation,  and  borbyrigmus  arise.  Dragging  sensations,  fatigue,  debility, 
multiple  nervous  symptoms.  In  general  the  symptoms  of  coloptosia  are 
stenosis  compromised  and  irregular  caliber,  dilatation,  retention,  obstruction, 
constipation,  disturbed  circulation  and  ennervation,  relaxed  abdominal  wall, 
pendulous  abdomen,  practical  relief  of  symptoms  on  assuming  the  prone 
position. 

The  dislocation  of  the  colon  favors  constipation  because  the  defective 
abdominal  wall  has  lost  its  effective  power  to  force  the  faeces  distalward. 
Since  in  dyspepsia,  nervopathies  of  the  tractus  intestinalis,  no  local  subjec- 
tive pain  is  experienced  hy  the  patient,  we  do  not  palpate  the  abdomen 
sufficiently  frequently.  First  and  foremost  we  should  palpate  the  abdomen 
to  determine  whether  the  pathologic  physiology  of  the  tractus  intestinalis  be 


592  THE   ABDOMIXAL   AXD   PELVIC  BRAIN 

secondary  or  primary.  Many  diseases  have  an  intestinal  origin.  Dyspepsia 
refers  to  the  stomach  only. 

Splanchnoptosia  is  a  disease  of  malnutrition.  Palpation  of  the  tractus 
intestinalis  attempts  to  explore  systematically  the  various  segments  and 
susceptibility  to  pain  caliber,  contents,  tension,  and  mode  of  fixation. 
Simon's  method  of  rectal  exploration  with  the  hand  we  discard  as  unsuitable. 
In  palpation  of  the  abdomen  we  must  devote  sufficient  time  to  understand 
the  occasional  variation  in  the  aortic  rhythm.  As  to  Glenard's  colic  cord 
we  must  consider  the  small  contracted  stomach,  the  pancreas  and  colon 
transversum,  as  any  one  may  be  mistaken  for  the  ""colic  cord."  Whatever 
this  cord  can  be,  found  in  perhaps  10r/c  of  splanchnoptoses,  we  should  attempt 
to  note  its  accessibility,  position,  length,  form,  volume,  consistence,  mobility, 
sensation.  In  palpation  the  idea  of  gliding  the  intestinal  segments  under 
the  hand  or  gliding  the  hand  over  them  must  be  practiced.  The  colic  cord  is 
located  in  the  relation  with  the  umbilicus.  In  the  diagnosis  of  coloptosia 
search  should  be  made  for  colonicptosia,  dilation,  constriction,  stenosis, 
atony,  decalibration,  obstruction,  retention. 

Diagnosis  of  coloptosia  ma}'  be  confirmed  by  colonic  inflation  per  rectum 
whence  one  can  by  inspection  and  percussion  trace  the  course  of  the  colon 
fairly  accurately.  By  palpation  one  may  manipulate  the  colon.  Glenard 
mentions  a  diagnostic  clue  to  coloptosia  transverse  which  he  calls  "corde 
colique  transverse" — the  cord  of  the  transverse  colon.  I  have  practiced  on 
this  subject  in  the  dead  splanchnoptotic  and  it  is  my  opinion  that  Glenard's 
cord  of  the  transverse  colon  is  simply  the  pancreas  in  general.  It  may  be 
possible  from  the  direction,  dimension,  location,  consistence,  mobility, 
sensibility,  inflation,  of  the  '"colic  cord"  to  detect  the  transverse  colon  in 
splanchnoptosia.  The  cecum  and  right  colon  will  be  best  located  by 
inflation  whence  inspection  and  percussion  are  further  aids.  We  must 
attempt  to  note  the  location,  dimension,  consistence,  mobility  of  the  cecum 
and  right  colon. 

In  the  diagnosis  of  coloptosia  the  means  at  hand  are  (a  >  inspection;  (b) 
palpation;  (c)  distension,  inflation;  (d)  consistence;  (e)  mobility;  (f)  sen- 
sibility;  (g)  colonic  peristalsis. 

Treatment. 

The  treatment  of  coloptosia  is  medical,  mechanical,  surgical. 

1.  Medical  treatment  is  comprised  in  diet,  regulation  of  function,  ample 
anatomic  and  physiologic  rest  and  appropriate  hygiene.  First  and  foremost 
is  what  we  term  "visceral  drainage."  By  appropriate  food  which  results  in 
ample  faecal  residue,  copious  fluids  at  regular  intervals  with  established  hours 
for  evacuation.  It  may  be  practically  claimed  that  every  case  can  be  con- 
trolled. If  colonic  secretion,  absorption  and  peristalsis  be  appropriately 
stimulated  by  proper  food  and  ample  fluid  the  colonic  circulation  and  in- 
nervation will  practically  remain  normal  and  the  coloptotic  though  necessarily 
afflicted  with  a  certain  amount  of  pathologic  physiologic  physiology  will 
remain  practically  with  a  few  symptoms. 


SPLANCHNOPTOSIA  593 

2.  Mechanical  treatment  comprises  abdominal  bands,  corsets,  adhesive 
strapping,  prone  attitude.  Adhesive  strapping  (of  Achilles  Rose),  which  is 
economical,  practical  and  rational,  has  in  my  practice  rendered  much  comfort 
to  patients. 

3.  Surgical  treatment  in  coloptosia  is  absolutely  limited.  It  comprises 
two  methods,  viz.:  (a)  operations  on  the  colon  itself,  fixing  it  to  the  abdom- 
inal wall  or  other  viscus — colopexy.  As  coloptosia  is  but  a  part  and  parcel 
of  splanchnoptosia,  colopexy  is  limited  in  its  range  and  rational  application, 
(b)  The  surgical  treatment  of  diminishing  the  space  of  the  peritoneal  cavity 
by  incising  the  abdominal  and  reuniting  by  superposition,  overlapping  its 
fascial  and  muscular  walls  like  a  double  breasted  coat,  though  limited  in 
application,  is  the  more  rational.  This  treatment  attempts  forcible  retro- 
position  of  the  colon  to  its  normal  location  and  maintenance  in  its  normal 
visceral  shelf  by  the  abdominal  wall. 

Enteroptosia. 

In  enteroptosia  the  enteron  passes  distalward  and  ventralward.  In 
advanced  cases  the  enteron  passes  almost  entirely  into  the  lesser  pelvis.  In 
this  condition  the  transverse  duodenum  is  compressed  against  the  vertebral 
column  by  the  superior  artery,  vein  and  nerve — the  axial  cord  of  the  mesen- 
teron  producing  gastro-duodenal  dilation.  If  the  abdominal  wall  becomes 
relaxed  the  mesenteron  becomes  elongated  from  the  viscera  following  the 
walls,  the  enteronic  loops  pass  distalward  into  the  pelvis  and  ventralward  in 
contact  with  the  relaxed  abdominal  wall.  Besides  the  basal  mesenteronic 
insertion  on  the  dorsal  wall  passes  distalward. 

In  advanced  enteroptosia,  the  enteron  experiences  mulitple  flexions, 
stenoses,  dilation,  dislocation,  compromising  circulation  (faecal,  blood  and 
lymph),  peristalsis,  decalibration  and  traumatizing  nerve  periphery.  In 
enteroptosia  the  enteron  not  only  changes  its  location  but  also  its  form, 
hence  pathologic  physiology  must  be  expected  as  altered  secretion,  absorp- 
tion, peristalsis,  and  sensation.  The  blood  and  lymph  circulation  is  com- 
promised by  flexion,  elongation,  contraction  or  dilation  of  the  vascular 
channels  ending  in  malassimilation. 

The  splanchnoptotic  is  continually  in  the  condition  of  pathologic  physi- 
ology. In  splanchnoptosia  absorption,  secretion  and  sensation  are  disturbed, 
the  blood  and  lymph  occupy  the  greater  and  lesser  pelvis,  hence  the  nerves 
and  vessels  are  placed  on  tension,  in  which  the  soft  walled  veins  and 
lymphatus  suffer.  In  the  examination  of  the  abdomen  for  enteroptosia,  in- 
spection, palpation,  percussion,  attitude,  location  the  gliding  movement,  aus- 
cultation the  belt  test,  gurgling,  should  be  employed.  The  consistence, 
limited  dimension  and  multiple  enteronic  coils  increase  the  difficulty  in 
diagnosis.  The  enteronic  coils  are  confined  in  the  colonic  square,  greater  and 
lesser  pelvis.     Attenuated  abdominal  walls  aid  in  diagnosis. 


594  THE  ABDOMINAL   AXD   PELVIC   BRAIN 

NEPHROPTOSIA    IN    SPLANCHNOPTOSIA. 

Fixation  of  the  Kidney  (traetus  urinarius). 

The  two  most  important  factors  maintaining  the  kidney  in  position  are 
the  muscular  action  of  the  diaphragm  and  abdominal  wall.  The  action  of 
the  diaphragm  is  direct,  that  of  the  abdominal  muscles  indirect  through  the 
adjacent  viscera.  Ventral  to  the  right  kidney  are  the  liver,  duodenum,  colon 
and  enteron.  Ventral  to  the  left  kidney  are  the  stomach,  spleen,  colon  and 
enteron.  Next  to  the  muscles  in  importance  is  the  perirenal  tissue — the 
fatty  capsule  in  which  the  kidney  lies  imbedded. 

The  perirenal  areolar  tissue  binds  the  kidney  to  the  diaphragm  and  at 
the  proximal  renal  pole  it  fuses  with  the  meshepaticon  on  the  right  side 
while  on  the  left  side  the  perirenal  tissue  fuses  with  suspensory  ligament  of 
the  spleen  and  coronary  ligament.  A  strong  renal  support  is  the  renal 
pedicle  composed  of  the  renal  artery,  vein,  nerve  plexus,  lymphatics  and 
fibrous  sheath  which  emanates  from  the  radix  mesenterica.  The  renal  pedi- 
cle limits  the  extent  of  renal  motion  because  the  renal  artery  arises  so  near 
the  radix  mesenterica — the  coeliac  artery — that  its  origin  is  practically 
immobile.  The  kidney  possesses  no  visceral  shelf,  simply  a  shallow  renal 
fossa  or  niche.  It  lies  proximalward  and  distalward  on  the  dorsal  abdominal 
wall  in  a  shallow  renal  groove.  Hence  the  structures  or  bands  which  main- 
tain the  kidney  in  position  are:  (a)  the  diaphragm  and  abdominal  wall;  (b) 
perineal  capsule;   (c)   renal  pedicle;   (d)  viscera  (indirect). 

Respiratory  Movements  of  the  Kidney. 

The  respiratory  motion  of  the  kidney  is  due  to  the  contraction  of  the 
diaphragm  on  its  proximal  dorsal  surface.  The  kidney  experiences  respira- 
tion movements  which  include  all  splanchnoptotic  viscera.  The  proximal 
dorsal  surface  of  the  kidney  lies  on  the  diaphragm  (hence  diaphragmatic 
area)  while  the  distal  dorsal  surface  lies  on  the  lumbar  structures  (Psoas, 
quadratus  and  transversal  muscles,  hence  lumbar  area).  Inspiration  forces 
the  kidney  distalward  and  ventralward  (rotation)  by  means  of  the  diaphragm 
while  expiration  allows  the  return  of  the  kidney  to  its  physiologic  location 
(to  its  renal  niche  in  the  abdominal  wall).  No  doubt  the  ratatory  motion 
of  the  kidney  if  extensive  produces  pain  from  renal  pedicle  torsion.  (Dietl's 
Crisis). 

The  kidney  becomes  nephroptotic  by  decreasing  its  subdiaphragmatic 
space.  On  the  right  side  the  liver  and  kidney  completely  occupy  the  right 
subdiaphragmatic  dome  and  one  or  both  must  yield  in  splanchnoptosia  when 
the  subdiaphragmatic  space  is  diminished,  hence  Riedel's  lobe  or  nephroptosia 
or  both  results.  From  clinical  observation  it  may  be  observed  that  the 
right  kidney  is  manifestly  nephroptotic  10  fold  more  than  the  left  and  that 
woman  have  10  fold  more  nephroptosia  than  man.  However,  this  is  more 
apparent  than  real  and  refers  rather  to  palpable  degrees  than  to  actualities. 

If  one  examines  a  series  of  embryos,  no  difference  can  be  observed 
between  the  right  and  left  kidneys  in  males  and  females,  hence  the  difference 


SPLANCHNOPTOSIA  595 

in  position  and  degree  of  nephroptosia  is  a  post  natal  acquirement.  One 
special  variable  element  arises  and  progresses  after  birth  and  that  is  the  rela- 
tion of  the  coecum  to  the  kidney.  The  difference  in  position  of  the  kidney 
begins  in  male  and  female  at  pubertas.  At  pubertas  in  females  the  diameter 
of  the  interiliac  space  begins  to  increase  more  rapid  than  the  diameter  of 
the  intercostal  space  producing  a  distalward  expanding  funnel  in  the  body 
trunk  and  this  truncated  funnel  is  irregularly  compressed  by  the  construction 
of  clothing  aiding  to  force  the  viscera  distal  to  the  corset  line  of  constriction. 
In  long  trunked,  waisted  women  the  constriction  of  the  corset  may  force  the 
kidney  proximalward  dorsal  to  the  liver  surface.  In  short  waisted  women 
the  corset  is  the  more  liable  to  force  the  kidney  distalward  extending  it  from 
the  costo-diaphragmatic  space  where  it  is  palpated  with  facility. 

The  Relation  of  Nephroptosia  to  the  Liver  or  Bile  Ducts. 

The  nephroptotic  kidney  maintains  two  relations  with  the  liver,  viz.: 
(a)  The  kidney  may  be  extended  distal  to  the  liver  when  its  peritoneal  and 
subperitoneal  tissue  connections  may  produce  traction  on  the  biliary  passages, 
flexing  and  obstructing  them  a  distalward  nephroptosia.  I  published  such 
a  case  with  illustration  in  the  Medical  Critic,  May,  1903.  In  this  subject  a 
peritoneal  band  extended  from  the  kidney  to  the  ductus  choledochus  commu- 
nis, (b)  The  nephroptotic  kidney  may  pass  proximalward  on  the  dorsal  sur- 
face of  the  liver.  This  is  proximalward  nephroptosia — a  symptomless 
dislocation.  The  influence  of  the  nephroptotic  kidney  on  the  colon  (hepatic 
flexure)  or  coecum  is  marked,  however,  limited  in  clinical  influence. 

Nephrotosia  ends  in  compromising  of  the  subdiaphragmatic  space,  as: 
(1)  contraction  of  the  diaphragm  on  a  relaxed  abdominal  wall  (as  in  respira- 
tion). (2)  by  collapse  of  chest  walls  (consequent  to  disease);  (3)  constric- 
tion of  the  trunk  (by  clothing).  The  left  kidney  is  limited  in  motion  in 
nephroptosia  because  it  is  maintained  in  position  by  the  splenic  flexure  of 
the  colon. 

The  production  of  appendicitis  by  nephroptosia,  as  reported  by  Edebohls. 
I  have  been  unable  to  confirm  clinically  or  by  autopsy. 

Nephroptosia  has  no  special  influence  on  disease  of  the  tractus  genitalis. 
In  nephroptosia  the  essential  element  to  observe  is  the  ventralward  displace- 
ment produced  by  axial  rotation  on  the  renal  pedicle  induced  by  the  dia- 
phragm and  which  constitutes  the  mobile  kidney  that  rotates  on  its  pedicle 
occasioning  a  "crisis."  It  is  not  the  distalward  nor  proximalward  dislocation 
of  the  kidney  that  produces  the  so-called  crisis. 

Nephroptosia,  Ren  Mobilis. 

Floating  or  movable  kidney,  Nephroptosia,  has  received  the  major 
attention  in  splanchnoptosia  and  has  unfortuately  been  the  scapegoat  for  the 
numerous  symptoms  belonging  to  general  splanchnoptosia.  It  is  admitted 
that  nephroptosia  may  be  the  most  striking  feature  in  the  examination  of 
the  splanchnoptotic  patient,  however,  in  the  vast  majority  of  subjects  it  is 
but  a  part  and   parcel  of  splanchnoptosia.     What  is  nephropotsia?     It   is 


596 


THE  ABDOMIXAL   AXD  PELVIC  BRAIX 


understood  to  be  excessive  renal  mobility.  The  kidney  is  a  mobile  organ, 
not  absolutely  fixed.  It  moves  with  respiration,  perhaps  Vi  an  inch  of  range. 
It  is  difficult  to  draw  the  line  between  a  normally  mobile  kidney  and  a  path- 
ologic one  except  through  complex  clinical  symptoms. 

Perhaps  10$  of  subjects  only  possessing  palpably  mobile  kidney  suffer 
from  nephrcptosia.  In  my  practice  among  women  I  have  palpated  and 
perceived  mobile  right  kidney  in  609c  of  subjects.  However,  60 x  of 
patients  were  not  afflicted  with  nephroptosia — floating  kidne\ — as  no  symp- 
toms existed.  In  some  700  personal  autopsic  abdominal  inspections  I  found 
that  the  general  movement  of  the  right  kidney  in  its  f jssal  bed  was  one  inch 


Fig.  19L  This  figure  presents  established  hepatic  dislocation.  1, 
diaphragm  ;  2,  meshepaticon  ;  3,  lobus  dexter  hepatis  ;  4,  ligamentum  suspen- 
sorium  hepatis  ;  5,  colon  transversum  ;  6,  enteron. 


proximalward  and  one  inch  distalward.     The  left  kidney  moved  about  one- 
quarter  of  an  inch  less  in  its  proximalward  and  distalward  translations. 

In  the  bodies  of  large  men  the  right  kidney  would  not  infrequently  move 
over  \)z  inches  proximalward — a  range  of  renal  movements  of  over  3  inches 
iproximo-distalward).  ('However,  it  is  my  opinion  that  the  dorso-ventral 
renal  motion — the  axial  rotation  of  the  kidney  on  its  neuro-vascular  visceral 
pedicle  that  inflicts  damage  and  pain.)  These  subjects  during  life  had  not 
complained  of  mobile  kidney  nor  had  it  been  diagnosed.  From  the  indura- 
tion of  the  perirenal  areola,  fatty  capsule,  the  kidney  has  a  greater  range  of 
motion  in  the  living  than  the  dead. 


SPLAXCHXOPTOSIA  597 

Etiology  of Nephroptosia. 

The  main  causes  are:  (a)  a  predisposing  body  form;  (b)  rapid  loss  of 
perineal  fat;  (c)  rapidly  repeated  gestations;  (d)  heredity — degeneration, 
inferior  anatomy  and  physiology;  (e)  yielding  of  diaphragmatic  supports; 
(f)  debilitating  disease,  form  and  dimension  of  the  renal  fossa.  The  renal 
fossa  varies  in  form  and  dimensions  within  certain  limits  in  different  individ- 
uals. The  narrower  the  distal  end  of  the  renal  fossa  the  more  immobile  the 
kidney.  The  renal  fossa  is  broader  and  shallower  in  woman  than  man,  hence 
more  ren  mobilis  in  woman  than  man.  The  broad,  shallow  fossa  renalis 
connected  with  a  funnel-shaped  trunk  accounts  for  increased  renal  mobility. 

Frequency  of  Nephroptosia. 

I  think  that  10%  of  female  adults  are  afflicted  with  symptomatic  nephrop- 
tosia. In  60%  of  adult  women  visiting  my  office  I  can  palpate  mobile 
kidney. 

Age  Relations  of  Nephroptosia. 

Nephroptosia  is  at  its  maximum  frequency  and  extent  at  40  years  of  age. 

Diagnosis  of  Nephroptosia. 

Nephroptosia  is  diagnosed  by  bimanual  palpation  in  the  lumbar  region 
while  the  patient  assumes  the  dorsal,  prone,  semi-prone  and  erect  attitude. 
Mobile  kidney  should  not  be  mistaken  for  neurosis. 

If,  in  nephroptosia,  one  can  find  distinct  renal  pain,  renal  tenderness, 
renal  hypertrophy,  and  that  the  ureteral  pelvis  of  the  same  side  will  contain 
a  greater  quantity  of  fluid  than  the  other,  periodic  hydro-ureter  has  probably 
begun.  If  in  a  kidney  of  extensive  mobility  irregular  pain  presents  it  is 
probably  due  to  rotation  of  the  kidney  on  its  uretero-neuro-vascular  pedicle 
(Dietl's  crisis)  and  ureteral  dilatation  (periodic  hydro-ureter)  has  probably 
begun. 

Position  of  the  Kidney. 

In  about  15%  of  subjects  the  kidneys  are  of  the  same  level.  Doubtless 
the  combination  of  longer  right  renal  artery,  the  erect  attitude  (force  of 
gravity)  and  the  liver  explains  the  variation  in  position  between  the  right 
and  left  calyces  and  pelvis  (kidney). 

In  mammals  the  right  kidney  lies  more  proximal  than  the  left  because 
the  right  renal  artery  is  longer,  the  attitude  or  force  of  gravity  tends  proxi- 
malward  and  the  liver  does  not  wedge  itself  between  the  kidney  and  dia- 
phragm so  vigorously  as  in  that  of  man.  Also  the  left  liver  half  is  much 
more  developed  in  quadrupeds  than  man  and  hence  the  gastrium  and  spleen 
is  more  distalward  than  in  man.  Hence  taking  into  account  the  larger  size 
of  the  right  hepatic  lobe  and  the  larger  volume  of  the  embryonic  liver  which 
checks  the  growth  of  the  Wolffian  body  proximalward  (Strube)  it  would 
appear  that  the  liver  has  considerable  influence  in  the  more  distal  position 
of  the  right  than  the  left  kidney.  There  is  an  age  and  functional  relation 
of  the  position  of  the  kidney,  especially  in  children  and  women.     A  child's 


598  THE   ABDOMIXAL   AXD   PELVIC  BRAIN 

kidney  is  more  distal  than  that  of  an  adult  on  account  of  its  relative  small 
volume  and  large  volume  of  the  liver.  Also  during  reproduction  when  the 
elements  of  the  abdominal  wall  (elastic,  muscular  and  connective  tissue) 
elongate  and  separate,  allowing  the  kidney  to  move  distalward.  Besides  the 
splanchnoptosia  that  increase  after  30  years  of  age  lends  data  to  an  age  and 
functional  relation  of  the  renal  position. 

The  statment  is  common  among  general  surgeons  who  are  prone  to  per- 
form nephropexy,  that  the  right  kidney,  which  is  most  frequently  operated, 
extends  distalward  to  crista  iliaca.  However,  if  one  will  carefully  examine 
100  male  and  female  cadavers  in  regard  to  the  position  of  the  kidney  and  iliac 
crestit  it  will  be  found  that  the  distal  pole  of  the  male  kidney  will  be  chiefly 
jioi  an  inch  proximal  to  the  iliac  crest  and  that  the  distal  pole  of  the  female 
kidney  will  average  over  }4  inch  proximal  to  the  iliac  crest.  Perhaps  in  man 
10%  of  right  distal  kidney  poles  touch  the  iliac  crest  and  perhaps  20%  in 
woman  touch  the  iliac  crest. 

The  left  kidney  is  more  proximally  located.  When  the  distal  renal  pole 
projects  distal  to  the  crest  of  the  ilium  pathologic  conditions  (splanch- 
noptosia) will  probably  exist.  The  kidneys  are  located  in  an  excavation 
(what  I  shall  term  renal  fossa)  on  the  dorsal  wall  of  the  abdominal  cavity 
on  each  side  of  the  vertebral  column  fixed  to  the  diaphragm  and  lumbar  mus- 
cle by  the  capsula  adiposa  renalis  or  perirenal  tissue,  anchored  medially  by 
the  neuro-vascular  renal  pedicle  and  maintained  ventrally  by  the  intra- 
abdominal pressure  (adjacent  viscera  and  abdominal  wall).  A  most  excellent 
and  practical  standard,  notwithstanding  individual  variations  for  kidney 
measurements  and  for  the  purpose  of  noting  the  position  of  the  kidney  is 
the  crista  iliaca.  I  used  it  as  the  chief  standard  in  all  measurements  in  some 
700  autopsies.  In  general  the  distal  pole  of  the  kidney  extends  to  the  IV 
lumbar  vertebra.  In  the  examination  of  over  620  cadavers  (man  465, 
woman  155),  the  general  average  was  that  the  right  kidney  was  one  finger 
(^inch)  proximal  to  the  iliac  crest  while  the  left  kidney  was  2  fingers  {1% 
inches). 

The  kidneys  of  woman  were  about  Vz  inch  more  distal  than  those  of  man. 
In  about  15%  of  the  females  the  right  distal  kidney  pole  was  on  a  level 
with  the  crista  iliac.  These  data  have  no  relation  with  the  artificial  range  of 
motion  that  one  can  impose  on  the  kidney  during  life  and  in  the  cadaver. 
The  kidneys  of  males  had  not  such  a  high  per  cent  of  distalward  position  nor 
such  free  motion  as  those  of  females.  However,  individual  variation  is 
prominent  for  in  some  male  cadavers  I  found  the  highest  form  of  free  mobil" 
ity,  e.  g.,  in  one  large  male  cadaver  the  right  kidney  presented  a  proximal- 
ward  range  of  2  inches  and  a  distalward  range  of  2  inches — a  total  vertical 
range  of  4  inches.  Conclusions  in  regard  to  the  factors  affecting  the  position 
of  the  kidney:  1.  The  chief  factors  in  retaining  the  kidney  in  position  is  the 
length  of  the  neuro-vascular  renal  pedicle,  in  short  the  arteria-renalis.  2. 
Pressure  and  counter-pressure  of  adjacent  viscera.  3.  Intra-abdominal 
pressure  (pelvic  and  thoracic  diaphragm  and  ventral  abdominal  walls).  4. 
Bodily  attitude  and    force  of  gravity.     In  man  the  right  kidney  is  located 


SPLANCHNOPTOSIA 


51)9 


distalvvard  to  the  left.  In  quadrupeds,  the  right  kidney  is  located  proximal 
to  the  left.  In  man  and  quadrupeds  the  right  arteria  renalis  is  the  longer. 
5.  The  shape  of  the  trunk,  especially  of  woman,  is  that  of  a  funnel  with  the 
larger  end  distalward.  G.  In  woman  age  and  functional  relations  aid  in 
inducing  nephroptosia.  7.  The  diminished  amount  of  panniculus  adiposus 
renalis,  through  absorption  tends  to  nephroptosia.  8.  Elongation  and 
separation  of  the  elements  (fascia,  muscle  and  elastic  fiber)  of  the  abdominal 
wall,  relaxation  are  among  the  most  potent  factor  as  regards  the  position  of 
the  kidney.     9.  The  peritoneum  aids  in  maintaining  the  kidney  in  position. 

10.  The  liver,  in  foetal  and 
adult  life,  the  long  right 
renal  artery,  the  absence  of 
the  colon  on  the  ventral  right 
renal  surface,  the  shallow 
right  renal  bed  or  niche  and 
the  less  strong  perineal 
fascia  in  the  right  kidney 
makes  the  right  kidney  more 
mobile  than  the  left. 


Symptoms   of  Nephroptosia. 

Among  the  chief  disturbing 
symptoms  of  nephroptosia  I 
think  is  renal  anteversion, 
torsion  of  the  renal  pedicle 
with  ureteral  flexion.  Tor- 
sion of  the  renal  pedicle  can 
be  observed  in  life  only  in 
the  erect  attitude  as  the 
recumbent  position,  imme- 
diately corrects  renal  dislo- 
cation. When  the  subject 
of  nephroptosia  sits  or  stands 
the  proximal  pole  of  the 
kidney  moves  ventralward 
producing  torsion  or  rotating  of  the  renal  pedicle  (artery,  vein,  nerves, 
lymphatics)  and  flexion  of  the  ureter.  Torsion  of  the  renal  pedicle,  renal 
anteversion,  compromises  the  renal  lymph,  venous  and  arterial  vessels  as  well 
as  traumatizes  the  nerves  in  the  renal  pedicle.  Doubtless  the  essential 
benefit  of  mechanical  abdominal  supports  in  nephroptosia  is  the  correction  of 
the  renal  anteversion  and  consequent  correction  of  torsioned  renal  pedicle. 
Doubtless  Dietl's  crisis  is  torsion  of  the  renal  pedicle.  Kidneys  with  ex- 
tensive range  of  motion  (3  to  4  inches)  in  the  living  may  be  accompanied 
with  no  symptoms.  We  frequently  observe  this  phenomena.  If  the 
proximal  pole  of  the  kidney  becomes  detached  from  the  diaphragm,  as  it 
does  in  nephroptosia  renal  anteversion  begins  its  slow  march  which  is  con- 


Fig.  192.  This  figure  represents  advanced  hepatic 
dislocation.  1,  diaphragm  ;  1,  hepaticon  ;  3,  dexter  et 
sinister  lobus  hepatis  ;  5,  ligamentum  rotundum  hepatis. 
The  liver  is  advanced  sufficiently  distalward  to  conceal 
colon,  enteron,  and  kidneys. 


600  THE   ABDOMINAL   AND   PELVIC  BRAIN 

tinually  accelerated  by  the  distalward  movements  of  the  liver  and  spleen 
through  the  contracting  diaphragm.  Renal  anteversion  and  consequently 
torsion  of  renal  pedicle  may  be  observed  in  the  large,  s;jare  splanchnoptotic 
multipara  by  palpating  especially  the  right  kidney.  During  the  last  15  years 
in  some  700  autopsies  I  have  tested  the  renal  range  of  motion  in  large 
numbers.  The  verticle  or  proximo-distal  translation  of  renal  motion  is  but 
a  factor  in  nephroptosia.  I  have  found  both  in  the  living  and  dead  that  the 
dorso-ventral  renal  translation  motion  and  the  torsion  or  twisting  of  the  renal 
pedicle  are  potent  factors  in  the  symptom-complex  of  nephroptosia. 

The  dorsal-ventral  movements  of  the  kidney  consists  of  ventralward 
motion  only  in  a  zone  of  perhaps  2  inches. 

Nephroptosia  comprehends  the  view  of  clinical  symptoms  complex  in 
which  the  role  of  dragging  sensations,  pain  in  the  anterior  crural  and  genito- 
crural  nerves,  gastric  crisis,  constipation,  dyspepsia  and  various  degrees  of 
neuroses,  violent  palpitation  in  the  epigastrium.  Pains  in  the  sacral  and 
lumbar  region.  Dietl's  crisis — paroxysmal  attacks  of  severe  and  intense 
pain,  nausea  and  vomiting.  Dietl's  crisis  may  be  due  to  torsion  of  the  renal 
pedicle  or  to  periodic  hydro-ureter.  We  may  note  improvement  during 
pregnancy  and  discomfort  during  menstruation.  Increased  symptoms  during 
walking  occur  and  relief  of  symptoms  on  assuming  the  prone  position.  The 
above  symptoms  simulate  those  of  splanchnoptosia.  Nephroptotic  symptoms 
are  generally  an  incident  only  in  splanchnoptosia.  A  warning  is  here  offered 
not  to  attribute  symptoms  to  nephroptosia  that  belong  to  splanchnoptosia. 
For  practically  nephroptosia  and  splanchnoptosia  are  coexistent. 

Treatment  of  Nephroptosia. 

I.   Medical. 

(a)  Visceral  drainage.  The  most  important  treatment  in  nephroptosia 
(which  practically  coexists  with  splanchnoptosia)  is  what  I  shall  term  visceral 
drainage,  i.  e.,  maximum  sewerage  or  flushing  by  ample  fluids  of  the  tractus 
intestinalis,  urinarius  and  perspirations  with  liberal  supply  of  coarse  foods 
which  leave  an  indigestible  foecal  residue  to  stimulate  peristalsis  in  the  colon, 
(b)  Position.  Nephroptoses  should  assume  the  recumbent  position  as  much 
as  convenient  for  they  possess  inferior  anatomy  and  physiology.  It  relieves 
symptoms — acts  as  a  prophylaxis  and  aids  in  curing  by  inducing  the  kidneys 
to  persist  in  their  normal  prevertebral  fossae.  (c)  Nutrition.  Improve 
nutrition  in  order  to  redeposit  the  perirenal  areolar  capsule,  (d)  Pregnancy. 
Gestation  improves  nutrition  (and  acts  as  a  temporary  mechanical  support), 
(e)  Massage,      (f)  Gymnastics,     (g)  Electricity. 

II.     Mechanical. 

Mechanical  treatment  signifies  forcible  reposition  and  retention  of  the 
kidney  in  its  normal  physiologic  location.  This  is  excuted  by:  (1)  Attitude. 
The  horizontal  position  relieves  symptoms  and  aids  in  curing  the  disease. 
(2)  Abdominal  binders,  (a)  These  may  be  elastic  or  nonelastic  and  are 
applied   during  the  day  (or  erect    attitude),     (b)  An  elastic   binder  which 


SPL.I.XCJLXOPTOSIA  601 

contains  between  the  binder  and  abdomen  a  pneumatic  rubber  pad  (Byron 
Robinson).  This  binder  is  applied  while  recumbent  and  the  pneumatic  pad 
distended  to  suit  the  comfort  of  the  patient.  (3)  The  corset.  This  method 
has  been  successfully  conducted  by  Dr.  E.  A.  Gallant  of  New  York.  The 
corset  is  made  under  individual  measurements,  applied  while  in  the  prone 
position  and  removed  for  the  recumbent  attitude.  (4)  Adhesive  strapping. 
This  is  executed  by  means  of  adhesive  straps  applied  to  the  abdomen  and 
is  known  as  Achilles  Rose's  method  (also  independently  introduced  by  Dr. 
N.  Rosewater  of  Cleveland,  Ohio,  and  Dr.  B.  Schmitz  of  Germany):  Straps 
of  adhesive  plaster  of  various  width  are  passed  entirely  around  the  body, 
elevating  and  maintaining  the  abdominal  viscera  in  the  normal  physiologic 
position.  Rose's  method  of  adhesive  strapping  is  simple,  economical, 
rational  and  of  vast  practical  utility.  (5)  Pregnancy.  Gestation  temporarily 
relieves  the  symptoms  of  nephroptosia. 

The  Effect  of  Relaxed  Abdominal  Wall  and  consequent  splanchnoptosia  in 

Neph  rop  to  si  a. 

Women  with  relaxed  abdominal  walls  frequently  suffer  with  nephrop- 
tosia. In  regard  to  the  nephroptosia,  the  renal  secretion  is  deficient,  excess- 
ive, or  disproportionate.  The  exact  relations  of  factors  of  the  nephroptosia 
and  relaxed  abdominal  walls  to  the  disturbed  renal  secretion  are  not  easy  to 
be  determined. 

The  disturbed  renal  secretion  would  appear  to  be  mainly  due  to  disturbed 
renal  mechanism.  The  renal  artery,  vein  and  ureter  become  compromised 
in  relation  to  the  nephroptosia.  The  passing  distalward  of  the  kidney  from 
relaxed  abdominal  walls  stenoses  the  ureter  and  renal  vein.  The  blood  pres- 
sure in  the  renal  vein  is  low,  and  hence  light  disturbed  renal  mechanism  will 
easily  compromise  its  blood  flow. 

In  nephroptosia  the  distal  pole  of  the  kidney  approaches  the  vertebral 
column  disproportionately,  and  hence  compromises  the  lumen  of  the  ureter, 
damming  the  urine.  Outside  of  disturbed  urine  flow  from  changed  renal 
mechanism,  equally  disturbing  factors  in  nephroptosia  arise  from  trauma  to 
the  renal  plexus.  The  renal  plexus  is  a  large  collection  of  nerve  plexuses  and 
ganglia,  and  besides  it  is  directly  connected  with  the  ganglia  coeliacum,  the 
abdominal  brain,  the  largest  ganglia  in  the  body,  which,  being  a  reflex  center 
outside  of  the  spinal  cord,  reorganizes  the  reflexes  and  sends  them  to  all 
other  abdominal  viscera.  Thus  the  patient  with  nephroptosia  complains  of 
nausea  and  vomiting  and  dragging  pains.  She  gradually  becomes  neurotic 
from  reflexes  due  to  trauma  on  the  renal  plexus.  The  damage  in  nephrop- 
tosia is,  perhaps,  in  order: 

1.  Trauma  of  the  renal  plexus  (and  abdominal  brain),  producing  a 
vicious  circle  by  continuous  reflexes  on  the  abdominal  viscera. 

2.  Traumatic  stenosis  of  the  vena  cava,  ovarian  and  renal  veins. 

3.  Stenosis  of  the  ureter  with  dislocation  of  the  kidney,  preventing 
drainage. 

4.  Trauma  of  renal  artery. 


602 


THE   ABDOMINAL   AND   PELVIC  BRAIN 


5.  A  combined  dislocation  of  the  renal  mechanism  is  changing  the  rela- 
tion of  the  renal  vein,  artery  and  ureter,  a  disturbed  mechanism  of  the 
uretro-ureteral  triangle. 

6.  The  producing  cf  deficient,  excessive  or  disproportionate  renal 
secretion. 

7.  The  subject  with  right  nephroptosis  suffers  nausea,  headache,  foul 
breath,  gastric  disturbances  and 
constipation,  accompanied  by 
the  stigmata  of  hysteria  and 
other  neuroses.  As  nephro- 
ptosia  is  only  a  part  and  parcel 
of  general  splanchnoptosis, 
nephropexy,  which  should  be 
done  by  placing  the  kidney  in 
the  abdominal  wall  without 
sutures,  must  be  limited  in  its 
local  and  general  utility,  prac- 
tically to  periodic  hydroureter. 


The  Uretero-Vcnoits  Triangles. 
{Byron  Robinson.) 

In  dissecting,  one  finds  on  the 
left  side  of  the  body  a  triangle 
formed  by  the  ureter  on  the  left 
side,  the  ovarian  vein  on  the 
right  side,  and  the  renal  vein 
on  the  proximal  end  or  base. 
The  sides  of  the  triangle  are 
about  2  to  o  inches  and  the  base 
(the  renal  vein,)  is  about  1  inch. 
The  apex  of  the  triangle  is  at 
the  proximal  arterio-ureteral 
crossing  of  the  utero-ovarian 
artery,  located  proximal  or 
distal  to  the  iliac  crest. 

This  is  what  I  term  the  left 
uretero-venous  triangle.  Its 
outlines  are  distorted  in  left 
nephroptosis. 

On  the  right  side  of  the  body 
what  I  term  the  right  uretero-venous  triangle  is  formed  by  the  ureter  on  the 
right  side,  the  vena  cava  and  ovarian  vein  on  the  left  side,  and  the  renal  vein 
on  the  proximal  end  or  base.  The  right  uretero-venous  triangle  is  about  an 
inch  at  its  base  (the  renal  vein)  and  2  inches  on  its  sides.  Its  apex  is  at  the 
proximal  arterio-ureteral  crossing  of  the  utero-ovarian  artery,  and  is  located 
V/-2  to  2  inches  distal  to  the  iliac  crest.     The  significant  factor  in  the  right 


Fig.  193.  presents  a  common  condition  found 
especially  in  the  multipara.  The  left  kidney  is  pre- 
sented as  normal  to  compare  the  contrast.  1,  right 
kidney  with  its  distal  pole  projecting  distal  to  the 
iliac  crest;  2,  the  elongated  right  arteria  renalis.  3, 
the  ureter  in  a  sinuous  course.  B,  point  where  vasa 
ovarica  crosses  ventral  to  the  ureter  (apex  of  utero- 
venous  triangles  of  author).  A  presents  the  apex  of 
the  utero-venous  triangle  of  the  left  side.  4,  left 
kidney.  5,  left  ureter.  6,  left  arteria  renalis.  O, 
oesophagus.  C,  arteria  coeliaca.  S,  arteria  mesen- 
terica  superior.     V,  vena  cava. 


SPLANCHNOPTOSIA  603 

uretero-venous  triangle  is  that  in  nephroptosia  it  becomes  markedly  dis- 
torted, compromising  the  lumen  of  the  ureter,  ovarian  and  the  renal  veins. 
The  uretero-venous  triangles,  bilateral  distinct,  constant  structures,  are  signi- 
ficant landmarks  in  topographical  anatomy.  I  have  not  observed  them 
named  or  described.  They  vary  considerably  in  size  from  the  varying 
location  of  the  apex  at  the  crossing  of  the  ureter  by  the  ovarian  vein  and 
artery.  The  apex  of  the  uretero-venous  triangle  I  have  designated  as  the 
proximal  arterio-ureteral  crossing  (of  the  utero-ovarian  artery).  In  nephro- 
ptosia the  uretero-venous  triangle  is  distorted  and  the  lumen  of  the  vein  and 
ureter  is  compromised. 

III.      Surgical. 

Nephropexy  in  general  is  irrational  and  unjustifiable  (except  in  periodic 
hydroureter),  because:  (a),  it  is  unphysiologic  to  fix  mobile  viscera;  (bj,  the 
kidney  does  not  remain  fixed ;  (c),  the  nephroptosia  is  but  an  incident,  a 
fragment  of  splanchnoptosia;  (d),  the  remaining  or  adjacent  viscera  are 
deranged,  splanchnoptotic;  (e),  the  surgeon  attempts  to  relieve  one  lesion 
or  disease  (excessive  mobility)  by  producing  another  lesion  or  disease  (fix- 
tion ) — which  is  the  more  irrational;  (f),  the  multiple  methods  of  nephropexy 
condemn  it;  (g),  nephropexy  does  not  remove  the  splanchnoptotic  symptoms 
which  coexist ;  (h),  surgeons  do  not  agree  as  to  the  idications  for  nephropexy, 
as  the  symptoms  of  nephroptosia  are  not  proportionate  to  the  degree  of 
mobility;  (i),  the  mortality  of  nephropexy  is  at  least  1  per  cent;  (j),  nephro- 
pexy should  be  systematically  refused,  discarded,  condemned,  for  more 
rational  methods  (unless  periodic  hydroureter  exist).  The  therapeusis  should 
be  executed  through  the  abdomial  wall  (medical,  mechanical,  surgical).  The 
incised  abdominal  walls  should  be  superimposed,  overlapped  like  a  double- 
breasted  coat.  It  is  doubtfully  justifiable  to  perform  nephropexy  on  a 
replaceable  kidney  unless  periodic  hydroureter  can  be  demonstrated. 

Nephropexy  should  be  performed  only  after  all  palliative  measures  have 
been  tried. 

By  observing  the  final  results  of  nephropexy  extending  over  a  decade  and 
including  numerous  subjects,  it  is  not  flattering.  Professor  John  A.  Robison, 
of  Chicago,  relates  to  me  personally  that  during  the  past  ten  years  that  a 
considerable  number  of  his  patients  had  visited  different  surgeons  and  had 
undergone  the  operation  of  nephropexy.  Dr.  J.  A.  Robison  asserts  that  he  not 
only  observed  that  the  patients  received  no  benefits  from  the  nephropexy  but 
that  the  results  were  damaging  in  almost  every  subject. 

GASTRO-DUODENAL  DILATATION  IN  SPLANCHNOPTOSIA. 

A  Phase  or  Complication  in  Splanchnoptosia. 

The  dilatation  of  the  stomach  and  duodenum  (gastro-duodenal  dilation)  is 
due  to  pressure  of  the  superior  mesenteric  artery \  vein  and  nerve  on  the  tran- 
vsersc  segment  of  the  duodenum- 

In  1^93,  the  time  of  the  Chicago  World's  Fair  while  giving  courses  to 
physicians  on  abdominal  visceral  anatomy  and  its  applied  surgery,  I  became 


604 


THE  ABDOMINAL  AXD  PELVIC  BRAIN 


interested  in  the  manner  in  which  the  transverse  segment  of  the  duodenum 
was  compressed  by  the  superior  mesenteric  artery,  vein  and  nerve.  I  well 
remember  the  discussions  of  the  physicians  in  the  classes  at  that  time,  who 
concluded  that  the  superior  mesenteric  vessels  and  nerves  would  not  obstruct 
the  duodenum,  because  the  duodenal  contents  were  almost  entirely  fluid  and 
gas.  However,  we  all  observed  that  in  a  spare,  though  normal  subject,  the 
superior  mesenteric  vessels  and  nerves  very  suspiciously  compressed  the 
transverse  duodenal  segment.  We  selected  spare,  fatless,  subjects  for  vis- 
ceral demonstration,  and  the  distinct    mechanical  apparatus  of   mesenteric 


Fig.  194  is  a  cut  to  illustrate  the  position  of  the  duodenum  and  the  superior 
mesenteric  artery,  vein  and  nerve.  1,  the  superior  mesenteric  vein  ;  2,  superior 
mesenteric  artery,  the  nerve  not  represented  in  the  cut ;  3,  distal  end  of 
duodenum;  4  and  5,  stomach;  6,  hepatic  artery;  7,  splenic  artery;  8,  gastric 
artery,  the  hepatic  and  gastric  arteries  making  what  I  shall  term  the  gastro- 
hepatic  circle;  9,  the  oesophagus;  10,  the  gall-bladder;  11,  the  pylorus;  12,  the 
duodenum;  13  and  16,  gastro-epiploca  sinistra  et  dextra;  17,  spleen;  15,  part  of 
liver.  This  cut  shows  that  the  duodenum  in  the  acute  mesenterico-aortic 
angle  is  the  acute  mesenterico-vertebral — however,  the  real  angle  of  strangula- 
tion. 


vessels  and  nerve  clamping  the  transverse  duodenum  against  the  vertebral 
column  as  a  base  made  an  indelible  impression. 

I  have  persued  the  matter  during  the  past  thirteen  years  in  subjects 
possessing  visceral  ptosis,  and  found  that  when  the  coils  of  enteron  lie  in  the 
pelvis  the  superior  mesenteric  artery  vein  and  nerve  compress  the  transverse 
segment  of  the  duodenum  in  such  a  manner  that  gastro-duodenal  dialatation 
begins  in  the  transverse  segment  of  the  duodeum  immediately  on  the  right 
side  of  the  superior  mesenteric  vessels  and  nerve.     I  have  observed  this  so 


SPLAKCHXOPTOSIA 


605 


frequently  in  hundreds  of  autopsies  thatl  know  it  to  be  an  important  factor 
in  gastro-duodenal  dilatation  in  persons  suffering  from  visceral  ptosis, 
splanchnoptosia. 

Previous  to  1893  I  had  performed  a  considerable  number  of  autopsies, 
but  without  detailed  records  of  abdominal  inspection.  Since  1893  I  have 
detailed  records  of  personal  autopsic  inspection  of  the  abdomen  in  160  adult 


Fig.  195.  shows  the  relation  of  the  duodenum  transversum,  pancreas,  celiac 
axis,  superior  mesenteric  artery,  vein  and  nerve  with  the  stomach  drawn  proxi- 
mally.  1  and  2,  superior  mesenteric  artery  and  vein  ;  3,  aorta  ;  4  and  5,  transverse 
segment  of  duodenum  passing  posterior  to  vessels  ;  6  and  7,  pancreas  ;  8,  spleen  ; 
9,  splenic  artery;  10,  hepatic,  and  11,  gastric  arteries  forming  the  gastro-hepatic 
circle;  13,  portal  vein;  14,  duodenum ;  15  and  16,  stomach  ;  17  and  18,  epiploic 
arteries.  This  cut  shows  how  naturally  the  vessels  could  compromise  the  dis- 
talward-moving  fecal  current  in  the  duodenum.  The  fixation  of  the  transverse 
segment  of  the  duodenum  by  the  muscularis  suspensorius  and  the  fibrous  band 
from   the  left  crus  of  the  diaphragm  is  not  drawn  in  the  cut. 


females,  and  480  adult  males  and  some  50  children.  Besides,  I  have  -also 
pursued  the  study  of  visceral  ptosis,  and  relaxed  abdominal  walls — splanch- 
noptosia in  the  living  patients  and  abdominal  sections.  In  clinics  and 
autopsy  it  is  realized  with  facility  that  splanchnoptosia  is  a  frequent,  com- 
mon disease.  I  systematically  examined  in  the  700  detailed  autopsies  the 
tractus  intestinalis,  tractus  genitalis,  the  tractus  urinarius  and  also  the  peri- 
toneum. 

Since  Glenard's  celebrated  labors  on  splanchnoptosia  (1884)  considerable 


606  THE   ABDOMINAL   AND   PELVIC  BRAIN 

study  has  been  devoted  to  the  position  of  the  abdominal  viscera.  The  study 
of  the  position  of  the  abdominal  viscera  has  progressed,  however,  in  an 
irregular  method.  When  Dr.  Eugene  Hahn,  the  brilliant  Berlin  surgeon, 
first  introduced  and  performed  nephropexy,  superficial  surgeons  made  a  rush 
for  a  so-called  new  operation,  with  little  idea  that  nephroptosia  is  only  a 
part  and  parcel  of  general  splanchnoptosia.  Visceral  ptosis  may  begin  in 
early  years  of  age,  and  increases  every  subsequent  decade  of  life.  My 
knowledge  of  splanchnoptosia  or  visceral  ptosis  was  gained  during  the  past 
twenty  years  by  the  personal  autopsic  inspection  of  700  adult  abdomens,  50 
children,  quite  a  number  of  fetuses  with  hundreds  of  peritonotomies. 

I  have  been  for  years  attempting  to  prove,  by  post-mortem  examination 
and  peritonotomies  and  celiotomies,  that  in  a  considerable  number  of  cases 
dilatation  of  the  stomach  is  caused  through  pressure  of  the  superior  mesen- 
teric artery,  nerve  and  vein  on  the  transverse  segment  of  the  duodenum.  In 
these  subjects  the  stomach  does  not  begin  to  dilate  at  the  pylorus,  but  in  the 
duodenum  at  the  right  side  of  the  superior  mesenteric  artery,  vein  and  nerve. 
The  stomach  alone  is  not  dilated.  The  compression  of  the  duodenum  by 
the  superior  mesenteric  artery  and  vein  and  nerve  is  typically  manifest  in  a 
subject  with  splanchnoptosia  or  visceral  ptosis,  and  especially  while  lying  on 
the  back.  Practically  it  is  not  gastric  dilatation — it  is  gastro-duodenal 
dilatation. 

In  700  autopsies  I  have  noted  perhaps  50  advanced  typical  subjects 
presenting  some  distinct  and  some  extensive  gastro-duodenal  dilatation, 
which  began  in  the  duodenum  on  the  right  side  of  the  superior  mesenteric 
artery,  vein  and  nerve. 

The  careful  dissector  wonders  why  the  superior  mesenteric  artery,  vein 
and  nerve,  all  bound  in  a  strong  fibrous  bundle  and  tightly  compressing  the 
transverse  segment  of  the  duodenum,  do  not  produce  obstruction  in  the 
duodenal  segment  of  the  tractus  intestinalis.  At  first  thought  it  is  because 
the  bowel  contents  in  the  duodenum  is  liquid  or  gas.  This  may  be  always, 
or  nearly  always  true  in  absolutely  normal  subjects,  but  in  the  numerous 
subjects  with  splanchnoptosia  or  visceral  ptosis  it  is  not  true.  It  must  be 
remenbered  that  gastro-duodenal  dilatation  is  a  phase  or  stage  or  a  complica- 
tion in  progressive  splanchnoptosia.  The  more  splanchnoptosia  exists  the 
more  the  loops  of  the  enteron  pass  distalward  into  the  lesser  pelvis,  dragging 
and  tugging  on  the  superior  mesenteric  artery,  vein  and  nerve,  which  more 
and  more  tightly  constricts  the  duodenum  transversum,  because  the  latter 
scarcely  at  all  moves  distalward.  If  the  subject  possesses  considerable 
splanchnoptosia,  and  for  any  reason  lies  considerable  time  on  back,  the 
gastro-duodenal  dilatation  may  progress  quite  readily.  J 

The  most  typical  case  in  the  living  I  have  witnessed  was  one  to  whom 
Dr.  Coons,  of  Chicago,  called  me  in  1898.  The  patient,  a  man,  about  45 
years  of  age,  had  been  in  bed  perhaps  5  months  with  hip-joint  disease.  He 
had  some  lordosis.  The  abdomen  was  enormously  distended,  and  he  vomited 
continually.  I  thought  of  some  form  of  obstruction  in  the  tractus  intestinalis, 
and  proposed  that  abdominal  section  gave  the  only  faint  hope  of  relief.     The 


SPLAAiilXOPTOS/A 


r,07 


patient  quickly  and  cheerfully  gave  his  consent.  I  made  an  incision  in  the 
median  abdominal  line  and  found  the  abdomen  absolutely  filled  from  pelvic 
to  thoracic  diaphragm  with  a  white,  shiny  distended  cyst,  which  proved  to  be 
the  enormously  dilated  stomach  and  duodenum.  If  the  subject  had  been  a 
woman  the  tumor  would  be  immediately  taken  for  an  ovarian  cyst.  In  the 
patient's  debilitated  condition  I  could  do  nothing  with  such  an  enormous 
dilated  stomach,  and  finding  no  apparent  intestinal  obstruction  closed  the 
19,     f|fi?i      ^>>  abdominal  incision.     The 

m  patient  subsequently  died 

and  an  autopsy  was 
allowed.  We  found  the 
enormously  dilated 
stomach  and  duodenum — 
gastroduodenal  dilatation 
— caused  by  constriction 
of  the  superior  mesenteric 
artery  vein  and  nerve  on 
the  transverse  segment  of 
the  duodenum.  The 
subject  possessing  con- 
siderable degree  of 
splanchnoptosia  and  lor- 
dosis, with  several  months 
lying  on  his  back  in  bed 
made  the  progress  of  the 
gastro-duodenal  dilatation 
rapid  in  its  course. 
Gastro-duodenal  dilata- 
tion— a  slow,  gradual, 
chronic  process — doubt- 
less accounts  for  numerous 
so-called  idiopathic  gas- 
tric dilations  subsequent 
to  laparotomies.  The  ex- 
planation of  acute  gastric 
dilatation  (it  is  gastric- 
duodenal  dilation)  is  an 
exacerbation  of  chronic 
gastro-duodenal  d  i  1  a  t  a- 
tion.  In  every  fifty  autopsies  I  have  noted  typical  cases  where  it  was  gastro- 
duodenal  dilatation,  not  merely  gastric  dilatation.  In  many  cases  one 
observes  a  slight  dilatation  which  does  not  present  itself  as  typical,  but  by 
careful  examination  and  test  by  forcing  the  gaseous  contents  of  the  stomach 
through  the  duodenum  distinct  gastro-duodenal  dilatation  can  be  seen  to 
begin  at  the  right  side  of  the  band  formed  by  the  combination  of  the  superior 
mesenteric  artery,  vein  and  nerve. 


Fig.  196.  is  a  cut  to  illustrate  the  final  growing  gastro- 
duodenal  dilatation  due  to  obstructing  the  duodenum  by  the 
superior  mesenteric  artery,  vein  and  nerve.  The  white 
portion  of  the  stomach  and  duodenum  represent  the  nor- 
mal size,  the  adjacent  dark  portion  is  the  dilated  part.  1 
and  2,  the  superior  mesenteric  vein  and  artery;  3,  aorta; 
4,  the  non-dilated  portions  of  the  duodenum,  distal  to  the 
constricting  vessels ;  5  and  6,  original  normal  stomach;  9 
and  10,  the  non-dilated  duodenum;  11,  12,  13  and  14,  the 
dilated  portions  of  the  duodenum;  15,  the  hepatic,  and  16 
and  17,  the  gastric  arteries  forming  the  gastro-hepatic  cir- 
cle;  18,  aorta;  19,  celiac  artery  ;  20,  esophagus  ;  21,  hepatic 
artery;  22,  spleen;  23,  pylorus.  In  this  cut  the  acute 
mesenterico-vertebral  angle  shows  plainly  how  it  strangles 
or  obstructs  the  transverse  duodenal  segment  in  visceral 
ptosis. 


608 


THE  ABDOMIXAL  AXD   PELVIC  BRAIN 


One  can  easily  experiment  on  the  cadaver  to  prove  that  the  obstruction 
lies  at  the  point  of  the  duodenum  where  it  is  crossed  by  the  superior  mesen- 
teric artery,  veins  and  nerve.  By  placing  the  superior  mesenteric  artery, 
vein  and  nerve  on  a  tension,  i.  e.,  by  dragging  the  enteronic  loops  distalward 
and  compressing  the  gas  in  the  stomach,  the  obstruction  is  plainly  visible 
by  a  distension  of  the  duodenum  at  the 
right  side  of  the  structure  (vessels  and 
nerve)  which  constrict  the  duodenum 
transversum.  The  dilatation  is  caused 
first  by  gas  and  second  by  fluids.  I 
have  studied  the  subject  of  gastro- 
duodenal  dilatation  from  1893  and  since 
I  have  found  no  records  of  it  in  litera- 
ture, except  that  of  Albrecht,  in  1899, 
six  years  after  I  began,  it  seems  to  be 
original.  The  subject  of  gastro-duo- 
denal  dilatation  as  caused  by  the  con- 
striction of  the  superior  mesenteric 
artery,  vein  and  nerve  is  original  with 
me.  I  published  my  first  formal  article 
in  1900. 

Dr.  John  M.    T.    Finney,    associate 


professor  of  surgery  in  Johns  Hopkins 
medical  school,  wrote  the  following  in 
the  Annals  of  Surgery:  "It  is  a  fact 
worthy  of  note  in  passing  that  Dr. 
Byron  Robinson  of  Chicago  in  1900 
appears  to  have  been  the  first  one  in 
this  country  to  bring  this  condition  to 
the  attention  of  the  profession  in  a 
publication." 

In  1896  I  made  an  abdominal  au- 
topsy on  a  case  for  Dr.  Holman.  We 
found  extensive  gastro-duodenal  dilata- 
tion with  marked  distalward  disloca- 
tion of  the  stomach  (gastroptosia). 

The  woman  vomited,  I  was  in- 
formed, for  a  couple  of  years  before 
her  death,  which  appeared  during  life 
as  a  kind  of   marasmus.     Death   was 


Fig.  197.  a  profile  view  of  the  acute 
mesenterico-aortic  (mesenterico-vertebral) 
angle  presenting  the  method  of  duodenal 
obstruction  by  the  mesenteric  vessels. 
This  obstruction  is  especially  increased 
when  in  visceral  ptosis.  The  loops  of 
enteron  drag  on  the  superior  mesenteric 
artery  (3)  and  pass  in  the  direction  of  the 
arrow  toward  the  pelvis.  The  mesenterico- 
aortic  angle  (eventually  the  mesenterico- 
vertebral  angle)  has  already  advanced  to  a 
partial  obstruction  of  the  duodenum.  1, 
duodenum;  2,  aorta;  3,  superior  mesenteric 
artery;  4,  superior  mesenteric  artery  pass- 
ing to  coils  of  enteron;  5,  superior  mesen- 
teric angle  passing  to  colon;  6,  transverse 
colon  ;  7,  blades  of  omentum  majus  passing 
proximalward  to  gastrium;  3,  blades  of 
omentum  majus  passing  distalward;  10, 
inferior  mesenteric  artery;  11,  abdominal 
aorta  lying  between  the  origin  of  the  supe- 
rior and  inferior  mesenteric  arteries.  The 
arrow  points  to  the  pelvis  and  indicates  how 
the  superior  mesenteric  artery  clamps 
tighter  and  tighter  the  duodenum  with 
advancing  visceral  ptosis. 


undoubtedly  due   to  malassimilation, 

due  to  disturbances  in  the  system  caused  by  extensive  gastro-duodenal  dilata- 
tion. 

In  1895  Drs.  Fruth  and  Henry,  of  Ohio,  referred  to  me  a  patient  who 
had  scarcely  kept  fluid  or  food  long  in  the  stomach  for  twenty  months  or 
more.     She  was  emanciated,  and  I  could  detect  only  a  distended  or  dilated 


SPLANCHNOPTOSIA  609 

stomach.  The  gastroptosia  is  easily  detected,  for,  after  the  stomach  is  irri- 
gated, it  is  pumped  full  of  air  and  this  method  easily  demonstrates  its  outline. 
I  thought  this  patient  had  a  stricture  of  the  pylorus,  and  perhaps  a  carcinoma, 
but  she  did  not  lose  flesh  nor  had  she  paled  sufficiently  for  malignancy.  On 
opening  the  abdomen  all  we  found  was  an  enormous  gastro-duodenal  dilata- 
tion which  extended  distal  to  the  pelvic  brim,  yes,  into  the  lesser  pelvis. 
I  performed  gastrojejunostomy  with  my  segmented  rubber  plates.  She 
made  a  favorable  recovery,  and  wrote  to  me  seven  years  after  the  operation 
that  she  was  perfectly  well.  Dr.  Henry,  of  Fostoria,  Ohio,  her  physician, 
reported  in  1905,  ten  years  subsequent  to  the  operation,  that  she  is  well.  In 
hundreds  of  personal  autopsic  abdominal  inspections  I  have  noted  the  state 
of  the  duodenum  and  stomach  since  1893,  and  gastro-duodenal  dilatation  is  a 
common  disease  in  subjects  over  30  years  of  age,  especially  in  multiparae,  in 
whom  I  have  palpated  the  liver  partly  resting  in  the  lesser  pelvis.  After 
fifteen  years  of  observation  of  visceral  ptosis  I  am  convinced  that  gastro- 
duodenal  dilatation  is  the  indirect  cause  of  ill  health  and  of  many  deaths  in 
persons  above  thirty  years  of  age. 

Gastro-duodenal  dilatation  is  not  found  in  normal  subjects.  It  would 
appear  that  the  main  disturbance  in  gastro-duodenal  dilatation  begins  when 
the  enteronic  loop  passes  distalward  over  the  pelvic  brim  or  promontory.  It 
might  appear  strange  that  the  mechanical  arrangements  of  animal  structure 
would  tend  to  destroy  its  own  existence.  A  little  study  of  this  region  will 
explain  why  the  duodenal  obstruction  arises.  The  gist  of  the  explanation 
lies  in  the  anatomic  fact  that  (a)  the  transverse  duodenal  segment  in  the 
splanchnoptosia  does  not  travel  distalward  as  rapidly  as  does  the  enteron. 
(b)  In  adults  the  duodenum  possesses  a  mesenterii  membrana  propria  only 
(no  peritoneal  mesentery).  It  does  not  possess  a  peritoneal  mesentery. 
This  fact  alone  explains  why  the  duodenum  does  not  move  distalward  as 
rapidly  as  the  remaining  enteron,  which  possesses  a  6-inch  mesenteron.  (c) 
Again,  the  musculus  suspensorius  duodeni  of  Treitz  arises  adjacent  to  the 
coeliac  axis  and  inserts  itself  into  the  duodenum,  circumscribing  limited 
motion  to  it — duodenum — practically  imposing  localized  fixation  on  the 
doudenum.  This  second  important  anatomic  factor  serves  as  a  second 
explanation  why  the  transverse  segment  of  the  duodenum  does  not  pass  as 
rapidly  distalward  as  the  enteron,  which  is  maintained  by  an  elongated  mes- 
entery, (d)  A  third  explanation  why  the  transverse  duodenal  segment  does 
not  pass  distalward  as  rapidly  as  the  enteron  is  that,  the  transverse  duodenal 
segment  maintained  by  the  mesenterii  membrana  propria,  does  not  yield 
and  follow  the  relaxed  abdominal  walls  as  does  the  mobile  enteron.  Hence, 
since  the  transverse  segment  of  the  duodenum  does  not  travel  distalward  as 
rapidly  as  the  enteron  in  visceral  ptosis,  it  becomes  clamped  tighter  and 
tighter  in  the  diminishing  acute  angle  between  the  vertebral  column  and 
the  mesenteric  cord  (formed  by  the  mesenteric  vein,  artery  and  nerve).  The 
chief  clamping  of  the  duodenum  begins  when  the  enteronic  coils  pass  distal- 
ward into  the  lesser  pelvis.  The  expanding  and  proximalward  moving 
uterus   during   pregnancy  forces  the  enteronic  coils  proximalward,  increas- 


(510 


THE  ABDOMINAL   AXD   PELVIC  BRAIN 


ing  the  angle  between  the  vertebral  column  and 
mesenteric   artery,  vein  and  nerve),  and    this 


Fig.  198  shows  diagrammatically  how  the  superior 
mesenteric  artery,  vein  and  nerve  obstructs  the  trans- 
verse segment  of  the  duodenum  as  it  crosses  the  verte- 
bral column.  Increasing  enteroptosis  (i.  e.,  the  passing 
of  the  enteron  more  and  more  into  the  lesser  pelvis) 
makes  more  and  more  acute  the  mesenterico-vertebral 
angle,  and,  as  the  duodenum  does  not  pass  distalward  as 
rapidly  as  the  enteron,  obstructs  rapid  progress.  1, 
vertebral  column  ;  2  and  3,  normal  stomach  ;  4,  the  dark 
outline  represents  the  dilated  portion  ;  5,  superior  mes- 
enteric artery  ;  6,  superior  mesenteric  vein  ;  5,  6,  and  7 
are  bound  by  a  strong  sheath  of  connective  tissue  into  a 
bundle  as  large  as  the  little  and  ring  finger.  Occasion- 
ally in  visceral  ptosis  one  must  lift  several  pounds  in 
order  to  elevate  this  superior  mesenteric  band  from  the 
duodenum.  8,  the  white,  is  normal  duodenum;  9  and 
11,  dark,  is  the  dilated  portion  of  the  duodenum  due  to 
the  obstructing  mesenteric  vessels  and  nerve,  hence  the 
end  result  is  gastro-duodenal  dilatation;  11,  the  enter- 
onic  loops  in  the  pelvis  dragging  the  mesenteric  vessels 
over  the  sacral  promontory  like  a  rope  over  a  log.  The 
colon  transversum  is  resected  and  removed  P.  S.  In 
the  abdomen  of  such  a  case  of  visceral  ptosis  as  Fig.  184 
the  stomach  would  extend  to  the  sacral  promontory  and 
the  transverse  duodenum  would  be  relatively  slightly 
moved  distahvard  on  account  of  its  fixation  apparatus 
(i.  e.,  the  musculus  suspensorius  duodeni  and  the  fibrous 
band  connecting  the  duodenum  to  the  right  crus  of  the 
diaphragm).  In  enteroptosia  the  superior  mesenteric 
artery,  vein  and  nerve  must  elongate  and  attenuate, 
unlike  the  uterine  artery  in  pregnancy,  which  not  only 
elongates,  but  thickens. 


the  mesenteric  cord  (superior 
relieves  the  gastro-duodenal 
obstruction  similar  to  an 
abdominal  binder. 

One  scarcely  sees  the  duo- 
denum in  a  hernia.  The 
text-books  on  hernia  note 
that  every  organ  of  the  ab- 
domen has  been  found  in 
hernia  except  the  duodenum, 
pancreas  and  liver.  Dr. 
Lucy  Waite  and  myself  have 
made  autopsies  in  which  the 
stomach  rested  on  the  pelvic 
floor.  This  extends  tubular 
viscera  and  dislocates  the 
parts  so  that  partial  obstruc- 
tion arises  from  mesenterial 
vessels. 

In  1794,  when  Sir  Astley 
Cooper  and  Mr.  Cline  per- 
formed an  autopsy  on  Mr. 
Gibbon,  one  of  the  greatest 
of  English  writers  and  phi- 
losophers, they  found  the 
whole  tractus  intestinalis 
except  the  duodenum  (and 
cecum)  in  the  hernial  sac. 
The  distinguished  patient 
had  suffered  and  died  from 
a  left  inguinal  hernia,  and 
the  fact  of  the  long  con- 
tinued hernia  and  visceral 
ptosis  shows  that  the  trans- 
verse duodenum  is  the  last 
segment  of  the  tractus  intes- 
tinalis to  yield  to  the  drag- 
ging hernial  sac,  the  lax 
abdominal  wall  and  intra- 
abdominal pressure.  For 
thirty  years,  in  the  case  of 
Mr.  Gibbon,  the  duodenum 
transversum  had  resisted 
traction  of  the  hernial  sac 
and  intra-abdominal  pressure 
and  still  practically  retained 


SPLANCHNOPTOSIA  611 

its  relative  position.  The  scrotal  hernial  swelling  extended  to  his  knees, 
placing  all  neuro-vascular  visceral  pedicles  on  high  tension,  as  well  as  extend- 
ing pathologically  tubular  viscera  and  visceral  ligaments. 

I  have  observed  no  record  of  the  duodenum  or  pancreas  in  a  hernia.  My 
dissections  appear  to  demonstrate  the  musculus  suspensorius  duodeni  chiefly 
originates  in  the  tissues  about  the  coeliac  axis,  and  is  then  inserted  into  the 
duodenum  transversum  as  a  broad,  ribbon-like  muscular  band.  Besides  a 
powerful  fixation  apparatus  is  given  to  the  duodenum  by  a  strong  fibrous  (and 
perhaps  muscular)  band,  which,  by  traction,  shows  that  it  arises  from  the  left 
crus  of  the  diaphragm.  Hence,  the  coeliac  axis  and  the  crus  of  the  dia- 
phragm being  the  fixation  apparatus  of  the  transverse  duodenum  by  means 
of  the  musculus  suspensorius  duodeni  and  the  fibro-muscular  band  from  the 
crus  of  the  diaphragm,  the  duodenum  transversum  becomes  the  most  fixed 
organ  of  the  abdomen. 

Diagnosis  of  Gastro-Duodenal  Dilatation. 

To  be  useful  to  subjects  afflicted  with  gastro-duodenal  dilatation  (a  phase 
of  splanchnoptosia)  we  must  first  and  foremost  establish  the  diagnosis.  The 
first  postulate  to  entertain  is  that  in  established  splanchnoptosia  gastro- 
duodenal  dilatation — a  phase,  a  step  in  the  progress  of  splanchnoptosia — in 
all  probability  exists.  The  gastric  dilatation  can  be  established  with  facility 
by  aid  of  the  sodium  bicarbonate  and  tartaric  acid  test  of  the  forcing  of  air 
in  the  stomach  demonstrating  the  contour  of  the  stomach.  If  gastric  dilata- 
tion exists  in  splanchnoptosia  the  probability  is  that  duodenal  dilatation  also 
exists,  i.  e.,  gastro-duodenal  dilatation  is  the  probable  diagnosis.  To  my 
mind  this  explains  the  so-called  acute  idiopathic  dilatation  of  the  stomach 
subsequent  to  laparotomies.  A  factor  that  increases  gastro-duodenal  dilata- 
tion is  the  dorsal  position  of  the  patient  which  is  assumed  almost  immediately 
after  the  operation.  The  trauma  and  infection  resulting  from  manipulation 
of  the  viscera  becomes  suddenly  manifest  after  the  operation  by  paresis  of 
the  stomach  and  consequent  rapid  dilatation.  Splanchnoptotics  do  not 
resist  infection  vigorously.  The  gastric  fluids  and  gases  accumulate  and  not 
being  expelled  distalward  or  proximalward  distend  the  stomach.  There  is 
nothing  idiopathic  in  this  condition.  The  factors  are  evident,  viz:  (a)  a  pre- 
existing gastro-duodenal  dilatation  (splanchnoptosia);  (b)  gastric  (visceral) 
paresis  from  traumatic  manipulation;  (c)  gastric  (viscera)  paresis  from 
infection.  The  stomach  contents  of  patients  suffering  from  so-called  acute 
(idiopathic)  gastric  dilatation  subsequent  to  peritonotomy  seems  to  flow  out 
of  the  mouth  like  a  river— it  resembles  the  facile  flow  from  the  verticle 
stomach  of  an  infant.  The  treatment  for  such  patients  is  immediate  and 
repeated  gastric  lavage  furnishing  immediate  and  wonderful  relief.  All  fluids 
and  foods  for  such  a  patient  should  be  by  gradual  slow  rectal  irrigation — say 
a  pint  of  normal  salt  solution  should  be  introduced  in  the  rectum  every  two 
hours  and  require  thirty  minutes  to  flow  from  the  fountain  syringe  into  the 
rectum. 


Gl: 


THE  ABDOMIXAL   AND   PELVIC  BRAIX 


The   Treatment  of  Gastro-Duodenal   Dilatation  Due  to    Compression  of  the 
Superior  Mesenteric  Artery,    Vein  ami  Nerve. 

(1)  Medical;  (2)  mechanical;  (3)  surgical. 
/.     Medical. 

The  medical  treatment  has  regard  to  maintaining  normal  functions  of 
the  stomach  (and  other  viscera),  viz.:  (a)  sensation;  (b)  peristalsis;  (c) 
secretion ;  (d)  absorption.     The  functions  of  the  stomach  are  maintained  by 

appropriate  foods  and  fluids. 

(A)      Fluids. 

The  splanchnoptotic  requires 
ample  drainage  of  the  tractus 
intestinalis  (and  urinanus). 
The  patient  should  drink  eight 
ounces  of  fluid  (the  most  useful 
is  Vz  to  Y\  normal  salt  solution) 
ever)'  two  hours  for  six  times 
daily.  The  fluids  stimulate 
sensation,  peristalsis,  absorp- 
tion, secretion  in  the  stomach 
enabling  the  gastrium  to  wash 
itself,  to  irrigate  its  surface  and 
by  stimulation  of  its  muscularis 
to  evacuate  itself.  The  sodium 
chloride  stimulates  the  gastric 
epithelium.  The  fluid  increases 
the  blood  volume  (which  es- 
pecially stimulates  gastric  peri- 
stalsis), eliminates  waste  laden 
material  especially  through  the 
kidney  and  bowel.  In  order  to 
stimulate  the  tractus  intestinalis 
to  maximum  function  or  activ- 
ity I  add  to  the  eight  ounces  of 
one-half  normal  salt  solution 
every  two  hours  a  part  or  multi- 
ple of  an  alkaline  tablet  (com- 
posed of  cascara  sagrada  (1-40 
gr.),  NaHC03  (gr.  1),  KHC03 
(1-3  gr.),MgS04,  (2  gr.),  Aloes  (gr.  1-3).  The  tablet  is  used  as  follows:  One- 
sixth  to  one  tablet  (or  more  as  required  to  move  the  bowels,  once  daily)  is 
placed  on  the  tongue  before  meals  and  followed  by  8  ounces  of  water  (better 
hot).  At  10  a.  m.,  3  p.  m.,  and  bedtime  one-sixth  to  one  tablet  is  placed  on 
the  tongue  and  followed  by  a  glassful  of  fluid.  In  the  combined  treatment 
the  fragment  or  multiples  of  sodium  chloride  tablet  and  alkaline  tablet  are 


Fig.  199.  (author)  illustrates  the  superior  mesen- 
teric artery,  vein  and  nerve  bound  in  a  large  strong 
bundle  and  clamping  the  transverse  segment  of  the 
duodenum,  producing  gastro-duodenal  dilatation. 
1,  superior  mesenteric  vein ;  2,  nerve  and  third 
artery;  9,  the  duodenum  on  the  right  side  of  the 
vessels  and  nerve.  The  artery,  vein  and  nerve  forms 
the  mesenterico-aortic  angle,  but  the  actual  compres- 
sion angle  is  the  mesenterico-vertebral  angle.  The 
loops  of  enteron  are  drawn  to  the  left  in  order  to 
expose  the  vessels  and  nerve. 


SPLAXCHXOPTOSIA 


G13 


both  placed  on  the  tongue    together.     I    employ  for  the   sodium    chloride 
solution  or  NaCl  tablets  of  12  grains  each  and  use    fragments  of  it. 

(B)     Foods. 

Appropriate  foods  are  a  necessity  in  gastroduodenal  dilatation.  Food 
must  be  wholesome  as  cereals,  vegetables,  albuminoids.  All  fermentative 
foods  should  be  avoided,  as  pies,  cakes,  pastries,  puddings,  concentrated 
spices  and  condiments.  The  appropriate  food  excites  the  functions  of  the 
stomach  which  promptly  evacuates  itself.  If  food  remains  in  the  stomach 
for  over  3>2  hours  indigestion, 
fermentation  will  result.  In 
gastro-duodenal  dilatation  the 
essential  necessity  is  rapid  and 
complete  gastric  evacuation, 
i.  e.,  maximum  stomach  drain- 
age. In  gastro-duodenal  dila- 
tation two  conditions  exist, 
viz. :  (a)  one  is  where  the  py- 
loric ring  dilates  in  proportion 
to  the  gastro-duodenal  dilata- 
tion. This  condition  permits 
favorable  gastric  evacuation ; 
(b)  the  second  condition  is 
where  the  pyloric  ring  does  not 
dilate  in  proportion  to  the 
gastro-duodenal  dilatation. 
This  condition  is  unfavorable 
for  proper  gastric  evacuation 
and  is  a  serious  menace  to  the 
splanchnoptotic.  It  is  a  con- 
dition requiring  surgical  inter- 
ference— gastrojejunostomy. 

Maximum  nourishment  pro- 
duces and  maintains  a  normal 
panniculus  adiposus  which  aids 
to  maintain,  support,  viscera  in 
their  normal  physiologic 
position. 

Numerous  subjects  exist  with  advanced  gastro-duodenal  dilatation,  but 
do  not  suffer  marked  symptoms  because  physical  conditions  are  favorable  and 
the  pyloric  ring  is  ample  in  dimensions  to  allow  complete  gastric  evacuation. 
In  1894  Dr.  Lucy  Waite  and  I  performed  an  autopsy  on  a  man  70  years  of 
age.  We  found  gastro-duodenal  dilatation  advanced  to  the  degree  that  the 
stomach  rested  on  the  pelvic  floor.  No  record  of  any  symptoms  existed  dur- 
ing life  because  the  pyloric  ring  was  proportionately  dilated  with  the  gastrium 
and  duodenum  offering  limited  obstruction  to  the  evacuation  of  the  stomach 


Fig.  200.  An  illustration  of  the  clamping  of  the 
duodenum,  in  splanchnoptosia,  by  the  mesenteric 
vessels.  D,  duodenum,  the  enteronic  coils  are  well 
distalward  in  the  lesser  pelvis. 


614 


THE  ABDOMIXAL  AXD   PELVIC  BRAIN 


contents.  Whereas  in  another  autopsy  in  1895  on  a  woman  who  vomited  for 
two  years  with  gastro-duodenal  dilatation  the  data  was  reversed.  In  this 
female  subject  I  found  enormous  gastro-duodenal  dilatation  and  the  stomach 
projected  practically  to  the  lesser  pelvic  floor — however,  the  pyloric  ring 
was  remarkably  limited  in  dimension  and  gastric  contents  were  forced 
through  with  difficulty.  Residual  food  and  fermentation  occurred.  The 
continued  combined  treatment  of  the  3  pints  of  )i  sodium  chloride  solution 
and  alkaline  tablets  1-6  to  3,  as  required  to  move  the  bowels  once  daily,  are 
the  necessary  visceral  drainage  treatment  in  gastro-duodenal  dilatation 
(splcnchnoptosia).  -  The  alkaline  and  sodium  chloride  tablets  take  place  of 

the  so-called  mineral  waters.  I  con- 
tinue this  dietetic  treatment  of 
fluids  and  foods  for  weeks,  months 
(the  splanchnoptotic  requires  life- 
long treatment)  and  the  results  are 
remarkably  successful  especially  in 
pathologic  physiology  of  visceral 
tracts.  The  urine  becomes  clarified 
like  spring  water  and  increased  in 
quantity.  The  tractus  intestinalis 
becomes  freely  evacuated,  regularly, 
daily.  The  tractus  vascularis  in- 
creases in  volume  and  power.  The 
blood  is  relieved  of  waste  laden  and 
irritating  material.  The  tractus 
cutus  eliminates  freely,  and  the  skin 
becomes  normal.  The  appetite  in- 
creases. The  sleep  improves.  The 
patient  becomes  hopeful,  natural 
energy  returns.  The  sewers  of  the 
body  are  drained  and  flushed  to  a 
maximum.  Subjects  with  gastro- 
duodenal  dilatation  should  take  a 
limited  quantity  of  food  every  three 
hours  for  four  times  daily  so  that 
the  stomach  may  not  be  extensively 
distended  or  taxed. 


Fig.  201  represents  gastro-duodenal  dilata- 
tion ending  when  the  mesenteric  vessels  cross 
the  transverse  duodenum. 


//.     Mechanical. 

(i)  Abdominal  binders  generally  afford  comfort  and  relief  in  gastro- 
duodenal  dilatation  (if  the  pylons  is  proportionately  dilated).  The  kinds 
employed  are:  (a)  the  author's  pneumatic  rubber  pad  placed  within  an 
abdominal  binder  and  distended  to  suit  the  comfort  of  the  patient  (it  should 
be  removed  at  night).  (b)  E.  Gallant's  corset.  (c)  Achilles  Rose's 
adhesive  strapping.  The  above  mechanical  contrivances  afford  vast  comfort 
and  relief  in  gastro-duodenal  dilatation  by:  (1)  forcing  the  viscera  proximal- 


SPLANCHNOPTOSI.  /  615 

ward  in  their  normal  physiologic  position.  It  aids  the  stomach  in 
evacuation.  (2)  They  force  the  viscera  (especially  the  enteron)  proximalward 
and  increase  the  dimension  of  the  mesenterico-vertebral  angle  relieving  the 
transverse  duodenum  of  pressure  and  permitting  free  evacuation  of  stomach 
and  duodenum.  Achilles  Rose's  rubber  adhesive  strapping  is  particularly 
useful — rational,  practical,  economical. 

(2)  Position.  I  found  that  by  experimenting  with  the  dead  body  that 
position  had  much  to  do  with  the  pressure  of  the  mesenteric  vessels  on  the 
duodenum.  The  pressure  of  the  mesenteric  artery,  vein  and  nerve  on  the 
transverse  segment  of  the  duodenum  is  the  greatest  when  (a)  the  patient 
lies  on  the  back  and  the  enteronic  coils  lie  in  the  pelvis;  (b)  when  lying 
on  the  abdomen  the  pressure  is  mainly  relieved;  (c)  when  the  patient  is 
turned  on  the  side  the  pressure  is  relatively  light.  Hence  the  best  position 
of  the  patient  in  gastro-duodenal  dilatations  is  lying  on  the  abdomen;  and 
second,  lying  on  either  side.  Lying  on  the  back  or  standing  increases 
compressions  of  the  duodenum  by  the  mesenteric  vessels. 

III.     Surgical. 

Surgical  intervention  should  be  applied  to  gastro-duodenal  dilatation 
when  all  other  therapeutic  measures  have  been  tested  and  failed. 

(/)  Visceral  anastomosis  or  Gastrojejunostomy.  I  consider  one  of  the 
most  useful  surgical  methods  to  overcome  extreme  gastro-duodenal  dilatation 
is  gastrojejunostomy.  It  limits  the  food  journey  and  time  for  fermentation, 
and  facilitates  gastro-duodenal  drainage.  I  proved  in  gastrojejunostomy 
in  dogs,  ten  years  ago,  that  it  will  enable  the  stomach  to  completely  evacu- 
ate itself,  to  contract  because  the  food  does  not  tarry  in  the  stomach  but 
passes  immediately  into  the  jejunum  and  ileum,  the  business  portion  of  the 
tractus  intestinalis.  Any  segment  of  the  tractus  intestinalis  containing  no 
contents  or  over  which  no  food  travels  will  remain  contracted.  Anyone  can 
prove  this  by  excluding  a  segment  of  the  bowel  from  faecal  circulation;  it 
soon  contracts  and  remains  in  that  condition. 

Gastroenterostomy  is  the  most  certain  and  useful  of  all  operations  for 
gastro-duodenal  dilatation.  It  affords  the  one  necessity,  gastric  evacuation 
— complete  visceral  drainage.  I  have  reports  of  gastro-enterostomy  for 
gastro-duodenal  dilatation  of  12  years'  duration  and  perfectly  well. 

C?)  Superposition  of  the  abdominal  wall.  Longitudinal  overlapping  of 
the  abdominal  wall  resembling  a  double  breasted  coat  is  an  excellent  opera- 
tion for  some  subjects  afflicted  with  gastro-duodenal  dilatation.  I  perform  it 
with  permanently  burned  silver  wire  sutures,  three  to  the  inch.  In  the  Mary 
Thompson  Hospital  during  the  past  five  years  its  application  has  been 
remarkably  successful.  The  Mayos  have  advocated  the  proximo-distal 
superposition  of  the  abdominal  walls  (especially  in  umbilical  hernia). 

(3)  Resection  of  the  duodenum.  The  duodenum  could  be  resected  at  a 
point  to  the  right  of  the  constricting  mesenteric  vessels  and  its  divided  ends 
reunited  ventral  to  that  of  the  constricting  mesenteric  vessels.  Perhaps  it 
would  be  practically  better  to  perform  gastrojejunostomy. 


616  THE  ABDOMINAL  AND  PELVIC  BRAIN 

(4)  Enclosing  the  musculi recti-abdominales  in  a  single  sheath.  My  atten- 
tion was  called  to  the  subject  of  lax  abdominal  walls  by  Prof.  Karl  Schroeder, 
whose  pupil  I  was  for  a  year. 

In  that  year  (1884-1885)  Prof.  Schroeder,  the  greatest  gynecologic 
teacher  of  his  age,  was  at  the  zenith  of  his  fame,  and  his  clinic  was  vast ; 
in  fact,  he  tapped  the  whole  of  Europe  for  his  material.  He  discussed  in  his 
clear  style  the  misfortune  of  lax  abdominal  walls,  and  he  resected  large  oval 
segments  of  the  abdominal  wall  lying  between  the  diastatic  recti-abdominales. 
He  then  united  the  sheaths  of  the  recti  in  the  median  line.  But  Prof. 
Schroeder  said  then  to  his  pupils  that  he  was  not  fully  satisfied ;  however,  it 
was  the  best  surgery  that  he  knew  at  that  time.  Later  German  surgeons 
improved  on  Schroeder's  idea  by  splitting  the  sheath  of  the  recti  and  enclos- 
ing both  the  recti-abdominales  in  one  sheath  by  uniting  the  recti  sheaths 
ventral  and  dorsal  to  the  recti  muscles. 

In  1894,  Prof.  N.  Senn,  in  his  clinic,  began  splitting  the  sheaths  of  the 
recti-abdominales  and  uniting  the  sheaths  anterior  and  posterior,  enclosing 
both  musculi  recti-abdominales  in  a  single  sheath. 

In  1895,  Dr.  Orville  W.  MacKellar  and  I  operated  on  a  woman  pregnant 
for  five  months  for  an  ovarian  tumor  where  the  diastasis,  of  the  recti-abdom- 
inales was  very  marked,  and  the  uterus,  on  coughing  or  extra  intra-abdominal 
pressure,  would  project  between  the  recti-abdominales.  We  united  the  split 
sheaths  of  the  recti  ventrally  and  dorsally,  enclosing  the  two  musculi  recti- 
abdominales  in  one  sheath.  Dr.  MacKellar  reports  to  me  that  his  case  is 
perfectly  well  and  the  operation  was  a  success.  Dr.  MacKellar  was  at  the 
delivery  and  the  recti  sheaths  remain  perfectly  intact.  For  a  large  post- 
operative hernia  for  the  past  four  years  at  the  Mary  Thompson  Hospital  I 
have  split  the  recti  and  enclosed  them  in  a  single  sheath  for  every  one  with 
sufficient  experience  knows  that  the  post-operative  hernia  of  any  consider- 
able size  in  women  over  35  is  in  nearly  every  case  accompanied  by  visceral 
ftosis.  Dr.  MacKellar  and  I  have  records  to  show  that  ten  years  after  the 
enclosing  of  the  two  recti-abdominales  in  a  single  sheath  for  visceral  ptosis 
(utero-ptosis)  the  operation  is  a  success.  The  mesenteron  is  not  to  suspend 
the  enteron  but  to  act  as  a  neurovascular  visceral  pedicle  and  to  prevent 
the  enteron  from  entanglement  with  either  viscera.  It  is  the  abdominal  wall 
that  holds  the  viscera  in  position.  Besides,  I  showed  in  600  detailed  records 
of  personal  autopsic  abdominal  inspections  that  in  96  per  cent  of  subjects  the 
enteron  had  a  mesenteron  sufficiently  long  to  herniate  through  the  inguinal 
femoral  or  umbilical  ring.  Hence,  the  mesenteries  must  be  viewed  as  neuro- 
vascular visceral  pedicles,  and  not  as  suspensory  organs,  while  the  abdominal 
walls  are  the  great  supporters  and  retainers  of  the  viscera.  And  as  every 
anatomist  knows  the  recti-abdominales  are  among  the  chief  regulators  or 
governors  of  visceral  poise,  at  least  they  retain  the  viscera  in  their  first 
delicate  normal  balance.  Besides,  enclosing  the  recti  abdominales  in  a 
single  sheath  my  plan  of  operating  in  very  extreme  cases  is  to  sever  the 
recti-abdominales  and  invaginate  one  rectus  sheath  into  the  other  and  fix 
them  with  sutures.     This  is  similar  to  the  "stove  pipe"  operation  on  the 


SPL.LXCIIXOPTOSIA  G17 

intestines  that  I  presented  to  the  profession  in  1891  (Annals  of  Surgery,  1891 
and  "Practical  Intestinal  Surgery,"   L891). 

TRACTUS  GENITALIS   IN  SPLANCHNOPTOSIA. 

Fixation  of  the  Tractus  Genitalis. 
A.     Pelvic  diaphragm  (primary  support). 

Diaphragm  pelvis  consist  of  muculus  levator  ani  plus  its  superior  and 
inferior  fascia.     What  maintains  the  genital  organs  in  their  normal  positions? 

(a)  The  form  and  function  of  the  pelvic  floor  (levator  ani  with  its  proxi- 
mal and  distal  fascia),  (b)  The  position  of  the  genitals  and  the  adjacent 
viscera.  The  mesenteries  of  the  tractus  genitalis  (ligamenta  lata)  are  not  for 
mechanical  support.  They  are  to  conduct  vessels,  nerves,  and  to  maintain 
structures  in  order  for  function.  It  is  true  that  the  ligamenta  saco-uterina 
acts  as  vigorous  supports  if  placed  on  tension  but  in  their  present  normal 
state  of  existence  they  simply  direct  the  cervix  dorsalward.  The  vagina 
extends  from  the  pubus  to  the  cervix  and  the  sacro-uterine  and  the  liga- 
ments extend  from  the  sacrum  (rectum)  to  the  cervix.  Hence  the  vagina  and 
sacro-uterine  ligaments  act  as  a  supporting  beam  on  which  the  cervix  and 
uterus  is  supported.  The  same  story,  that  the  thoracic  and  abdominal  viscera 
are  chiefly  maintained  in  position  by  their  respective  walls,  is  true  as  regards 
the  position  of  the  pelvic  viscera,  and  its  walls.  The  so-called  uterine  liga- 
ment (mesenteries  of  the  genitals  act  only  in  pathologic  relations  as  in  sacro- 
pubic  hernia).  As  an  anatomic  demonstration  that  the  pelvic  floor  supports 
the  uterus  one  can  observe  (with  evacuated  bladder  and  rectum  and  uterus  in 
physiologic  position)  that  the  transverse  vaginal  slit  in  the  pelvic  floor  lies  2 
inches  ventral  to  the  cervix  (i.  e.,  the  corpus  uteri  lies  doro-ventral  across 
the  transverse  vaginal  slit).  If  pressure  be  exercised  on  the  corpus  uteri, 
exactly  as  intra-abdominal  pressure  is  applied  the  previous  position  of  the 
uterus  will  not  be  endangered,  i.e.,  it  will  not  enter  the  vaginal  slit  but 
simply  force  the  pelvic  floor  distalward.  In  other  words  the  pelvic  floor, 
the  distal  wall  of  the  pelvic  or  levator  ani  maintains  the  tractus  genitalis 
(uterus)  in  the  normal  physiologic  position.  If  one  wishes  (in  the  cadaver) 
to  force  the  uterus  through  the  vagina,  vaginal  slit  in  the  pelvic  floor  the 
hand  seize  the  fundus  and  corpus  while  the  cervix  is  pushed  vigorously  dis- 
talward in  the  vaginal  slit  where  the  cervix  may  be  observed  in  the  entroitus 
vaginae. 

If  the  pressure  is  removed  from  the  uterus  it  returns  to  its  normal  posi- 
tion. One  cannot  force  the  corpus  and  fundus  through  the  vaginal  slit  with 
any  ordinary  hand  power.  During  energetic  forcing  of  the  cervix  through 
the  vaginal  slit  the  ligamenta  rotunda,  ligamenta  lata  and  ligamenta  sacro- 
uterina  are  scarcely  put  on  tension  (they  are  entirely  secondary  supports). 
If  all  the  uterine  ligaments  are  severed  and  the  experiment  repeated  the 
cervix  can  be  forced  through  the  vagina  to  the  entroitus  only.  The  impos- 
sibility of  forcing  the  corpus  and  fundus  through  the  vaginal  slit  and  entroi- 
tus vaginae  is  due  to  the  increasing  volume  of  the  corpus  and  fundus  on 


G18  THE  ABDOMINAL  AND  PELVIC  BRAIN 

account  of  the  addition  of  the  oviducts,  vessels,  nerves,  and  ligamenta  lata. 
The  sacro-pubic  hernia  of  senescence  is  due  to  atrophic  conditions  of  the 
genitals  which  glide  through  the  vaginal  slit  from  diminutive  volume.  Zie- 
genspeck  claims  that  sacro-pubic  hernia  (uterine  prolapse)  is  due  to  the 
difference  between  intra-abdominal  pressure  and  atmospheric  pressure. 
Hence  the  primary  support  of  the  pelvic  viscera  (genitals)  is  the  pelvic 
floor — levator  ani  with  its  proximal  and  distal  fascia.  By  relaxation  it  in- 
cludes the  tractus  genitalis  in  splanchnoptosia. 

Diaphragma  thoracis  resembles  diaphragma  pelvis  in  physiology  and 
anatomy.  Both  have  (a)  a  similar  fixum  punctum  (circulatory  bony  origin), 
(b)  similar  punctum  mobile  (central  tendon),  (c)  both  support  superimposed 
viscera,  (d)  both  have  three  apertures  for  visceral  transmission,  (e)  both 
diaphragms  are  respiratory,  (f)  both  muscles  by  contsriction  limit  the 
apertures  of  visceral  transmission,  (g)  both  contract  as  a  single  muscle 
(h)  both  share  in  splanchnoptosia.  They  differ  in  that  contraction  of  the 
pelvic  diaphragm  draws  the  3  visceral  apertures  proximalward  and  ventral- 
ward,  while  contraction  of  the  thoracic  diaphragm  draws  the  visceral 
apertures  distalward  and  dorsalward. 

(B)  Ligmenta  Uterina  (secondary  supports). 

All  uterine  ligaments  arise  from  the  pelvic  wall  and  become  inserted  in 
the  lateral  borders  of  the  uterus.  They  act  as  guy  ropes,  to  maintain  the 
uterus  in  a  physiologic  position  in  order  to  functionate.  The  ligamenta  lata, 
the  real  neuro-vascular  visceral  pedicle  is  a  physiologic  support  only  not  a 
mechanical  serving  as  a  conducting  bed  for  vessels,  nerves  and  tubular  viscera. 
These  secondary  uterine  supports  in  splanchnoptosia  become  primary  which 
is  a  pathologic  condition. 

Movements  of  the  Tractus  Genitalis  During  Respiration. 

To  demonstrate  that  the  diaphragm  pelvis  is  a  muscle  sharing  in  respira- 
tion one  need  only  to  witness  a  single  perineorrhaphy.  Whence  the  proximal- 
ward  and  distalward  movements  of  the  levator  ani  are  evident.  To  prove  that 
the  genitals  share  in  respiration  one  need  only  to  observe  the  regular  motion  of 
6  month  gestating  uterus  or  the  motion  of  the  vagina  and  uterus  in  a  cough- 
ing anaesthetized  patient,  whence  not  only  the  blue  vagina  everts  through 
the  vaginal  slit,  but  the  uterus  may  also  be  present  at  the  pudendum.  The 
genitals  and  pelvic  floor  move  with  respiration.  The  respiratory  movements 
of  the  genitals  are  the  chief  factors  in  genital  ptosis.  To  illustrate  if  in  a 
case  of  uterine  prolapse  or  better  sacro-pubic  hernia  the  uterus  may  be 
returned  to  the  pelvis  and  the  patient  told  to  force  it  distalward.  She 
immediately  inspires  deeply  whence  she  retains  the  inspired  air,  ifixes  the 
thoracic  diaphragm,  and  forces  the  uterus  rapidly  distalward  through  the 
vagina  external  to  the  pudendum.  She  accomplishes  this  act  by  respiratory 
motion.  With  relaxation  of  the  pelvic  the  uterine  fundus  passes  dorsalward 
and  the  cervix  by  this  mechanism  gains  entrance  to  the  vaginal  slit  in  the 
pelvic  floor  whence  intra-abdominal  pressure  forces  the  uterus  distalward. 


SPLANCHNOPTOSIA  619 

If  the  uterus  loses  its  volume  becomes  atrophic,  respiratory  movements  may 
force  it  distalward  through  the  vaginal  slit  without  loss  of  integrity  of  the 
pelvic  floor. 

The  continual  respiratory  trauma,  when  visceral  supports  are  deranged, 
produce  progressive  sacro-pubic  hernia.  From  a  study  of  the  anatomic  sup- 
ports of  the  genitals  it  is  evident  how  irrational  are  the  surgical  attempts  to 
fix  the  uterus  in  some  preconceived  position  by  means  of  hysteropexy  or  the 
shortening  of  some  secondary  uterine  support.  It  appears  that  the  function 
of  respiration  is  not  confined  to  a  single  location  in  the  spinal  cord,  but 
extends  to  wide  areas  on  its  egress  nerves  so  that  man's  trunk  is  a  respiratory 
apparatus  closed  at  the  proximal  and  distal  end  by  a  diaphragm — both 
actively  involved  in  respiratory  movement.  The  relaxation  of  the  pelvic 
floor  and  consequent  genital  ptosis  is  simply  a  demonstration  of  the  patho- 
logic anatomy,  and  physiology  of  respiration.  The  genitals  present  various 
grades  of  splanchnoptosia.  In  the  first  place  the  portio  vaginalis  is  found 
moved  distalward  in  the  pelvic  axis,  the  corpus  may  be  in  normal  anteflexion, 
but  more  frequent  in  a  beginning  of  retroflexion — the  whole  uterus  is  excess- 
ively mobile.  In  the  second  place  the  entire  uterus  lies  parallel  and  against 
the  sacrum  (rectum).  The  cervix  is  not  infrequently  fixed  through  para- 
metritis posterior.  According  to  the  degree  of  genital  splanchnoptosia  arise 
pain  in  the  back  and  sacrum,  radiating  pain  in  the  extremities,  menstrual 
disturbances,  venous  congestion  and  constipation.  Later  the  cervix  projects 
through  the  pudendum.  Advanced  splanchnoptosia  of  the  genitals  presents 
prominent  features  of  relaxation  of  the  pelvic  floor  and  venous  congestion. 

Etiology  of  Genital  Ptosia. 

The  chief  etiology  of  genital  ptosia  is: 

(I)  Results  of  parturition,  i.  e.,  elongation,  separation  or  laceration 
of  the  pelvic  floor  tissue  (the  levator  ani  muscle  and  its  proximal  and  distal 
fascia). 

(II)  Atrophy  of  the  genitals. 

(III)  Respiratory  movements  forcing  the  genitals  distalward  (constantly 
forcing  the  deranged  genitals  in  the  direction  of  least  resistance). 

(IV)  Relaxation  of  the  thoracic  and  abdominal  walls. 

(V)  Superimposed  splanchnoptotic  viscera. 

(VI)  Genital  sub-involution  (infection). 

The  Treatment  of  Genital  Splanchnoptosia. 

The  treatment  should  be  medical,  mechanical,  surgical. 

/.     Medical. 

One  of  the  essential  remedies  is  visceral  drainage.  Hot  vaginal  douche 
(with  salt  and  alum  as  ingredients)  increased  to  12  quarts  which  contracts 
tissue  (elastic,  muscle,  connective),  massage,  electricity,  ample  and  horizontal 
rest  are  valuable  means.  The  boroglyceride  tampon  serves  as  an  excellent 
remedy.  It  is  hygroscopic  and  may  be  prepared  so  that  it  can  be  worn  one 
to  several  days. 


620  THE  ABDOMINAL  AND  PELVIC  BRAIN 

II.     Mechanical. 

The  horizontal  position  should  be  used  as  much  and  frequent  as  possible. 
Abdominal  binders  (in  which  may  be  placed  a  pneumatic  rubber  pad)  Achil- 
les Rose's  adhesive  strapping,  Galant's  corset  furnish  much  comfort.  Various 
kinds  of  pessaries  may  be  worn. 

III.     Surgical. 

Since  the  uterus  is  supported  by  the  pelvic  floor  rational  surgical  pro- 
ceedures  should  be  applied  to  it  in  splanchnoptosia.  Relaxed  pelvic  floor 
means  relaxed,  elongated,  fibrous  separation  of  the  levator  ani  with  its 
superior  and  inferior  fascia.  Hence  perineorrhaphy  should  include  the  care- 
ful repair  of  the  levator  ani  with  its  superior  and  inferior  fascia.  It  is  fascia 
that  supports,  not  muscle.  Ventral  colporraphy  aids  in  forcing  the  bladder 
proximalward  and  narrowing  the  vaginal  exit.  The  most  effective  and 
enduring  operation  for  splanchnoptotic  genitals  is:  (a)  amputation  of  the  cer- 
vix (if  required),  (b)  ventral  colporrhaphy  (c)  and  extensive  colpo-perineorra- 
phy,  i.  e.,  an  extended  Tait  flap  splitting  operation  with  reunion  of  the  torn 
muscle  and  fascia  of  the  levator  ani.  In  cases  of  uterine  atrophy  exten- 
sive vaginal  narrowing  is  required.  For  splanchnoptosia  of  the  genitals 
hysterectomy  should  not  be  performed  (as  it  renders  supports  less  efficient). 
The  uterus  is  the  key  to  the  support  of  the  genital  viscera.  I  have  seen  sub- 
jects of  splanchnoptotic  genitals  where  the  uterus  had  been  removed  and  sub- 
sequently the  everted,  distended  vagina  extended  to  the  middle  of  the  thigh 
with  almost  hopeless  views  of  repair.  As  to  suspending  or  fixing  the  geni- 
tals to  the  abdominal  wall  proximal  to  the  pelvis  it  is  an  irrational  operation, 
unphysiologic  and  harmful.  The  anatomy  and  physiology  of  the  genitals 
belong  to  the  pelvis. 

Ventral  abdominal  hysteropexy  should  not  be  performed  in  a  reproduc- 
tive subject.  Also  patients  do  not  present  symptoms  indicative  of  malposi- 
tion of  the  uterus.  The  position  of  the  uterus  has  no  special  relation  to 
disease.  As  the  symptoms  do  not  emanate  from  the  position  of  the  uterus 
fixing  it  will  have  no  relation  to  the  symptoms  (except  to  exacerbate  them). 
The  symptoms  of  patients  with  retroversions  for  example  emanate  from  other 
causes  than  the  uterus. 

RESULTS  OF  RELAXED  ABDOMINAL  WALLS  ON  THE  TRACTUS  INTESTINALIS. 

In  splanchnoptosia  one  of  the  most  damaging  influences  rests  on  the  trac- 
tus  intestinalis — sensation,  peristalsis,  absorption  and  secretion  are  deranged. 
The  normal  position  of  the  tractus  intestinalis  with  its  appendages  (liver, 
pancreas,  and  spleen),  is  changed  disordered.  The  circular  band  apparatus 
of  the  abdominal  wall  is  relaxed.  The  elongated  neuro-vascular  visceral 
pedicle  allows  the  segments  of  the  tractus  intestinalis  and  its  appendages 
to  follow  the  relaxed  abdominal  wall,  and  hence  move  out  of  their  normal 
physiologic  range,  compromising  blood  and  lymph  circulation  and  traumatiz- 
ing nerve  periphery.  There  is  at  once  a  disproportionate  action  between 
traumatized  nerve  periphery  and  separated,  elongated  fascial  and  muscular 


SPLAXCIIXOPTOSIA 


621 


fibres  of  the  abdominal  wall.  Muscular  tone  and  nerve  energy  become 
deranged.  Since  the  abdominal  wall  becomes  relaxed,  the  segments  of  the 
tractus  intestinalis  become  dislocated  permanently  from  a  normal  position. 
Since  the  neuro-vascular  visceral  pedicles  are  not  elastic,  and  not  for  the 
purpose  of  mechanical  support,  the  viscera  will  pass  distalward,  i.  e.,  in  the 
direction  of  least  resistance.  There  is  pathologic  physiology  and  pathologic 
anatomy.      The  spacious  abdominal  cavity  allows  the  viscera  to  shift  and 


Fig.  202.  Represents  the  surgical  procedure  which  encloses  the  musculi  recti 
abdominales  in  a  single  sheath.  1  and  2  represent  the  anterior  sheaths  of  the 
recti  partially  united  in  the  middle  lines.  10  and  12  represent  the  posterior 
sheaths  of  the  recti  partially  united  in  the  middle  line.  5,  the  linea  alba.  8  and 
9  the  recti  sheaths  lifted  up  to  show  the  recti  muscles.  This  operation  I  have 
employed  for  5  years. 

glide  from  weight  according  to  the  position  of  the  patient.  The  mesenteries 
of  course  elongate  when  their  essential  support,  the  abdominal  wall,  yields. 
The  visceral  supports  or  visceral  fixation  apparatus  are  (a)  the  abdominal 
wall,  (b)  the  pelvic  diaphragm,  (c)  the  thoracic  diaphragm  {d)  what  I  shall 
term  "visceral  shelves."     Any  yielding  of  any  one  of  these  segments  a,  b,  c, 


622  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

or  d  increases  the  abdominal  space  and  creates  a  disordered  relation 
between  viscera  and  supports  with  consequent  pathologic  physiology. 
It  may  be  a  neurosis  malassimilation  from  disordered  circulation  (lymph 
and  blood),  or  it  may  be  disordered  visceral  motion  (peristalsis)  from 
the  trauma  and  infection  of  the  ganglia  mysenterica  (Auerbach's  ganglia)  or 
disordered  secretion  from  disordered  action  of  the  Billroth-Meissner  plexuses 
from  trauma  and  infection.  Constipation  may  occur.  The  form  of  the 
abdomen  pendulous  shows  that  the  tractus  intestinalis  is  dislocated  distal- 
ward.  In  aged  and  spare  persons  the  actual  form  of  the  bowel  segments  and 
the  peristaltic  movements  may  be  observed  through  the  thin  abdominal  wall. 
The  tractus  intestinalis  in  splanchnoptosia  is  manifoldly  dislocated.  On 
account  of  the  fact  that  while  the  subject  of  relaxed  abdominal  walls  does 
not  manifest  the  disease  while  lying  on  the  back  because  the  abdomen  is  flat, 
the  autopsist  does  not  observe  the  splanchnoptosia.  It  is  the  clinician  who 
is  impressed  with  the  splanchnoptosia,  when  the  subject  is  in  the  erect  atti- 
tude manifesting  the  "hanging  belly,"  but  the  clinician  loses  his  usefulness 
because  he  scarcely  witnesses  the  autopsy.  It  is  the  clinical  and  autopsic 
observation  that  demonstrates  vividly  the  required  data.  The  great  segments 
of  the  tractus  intestinalis,  gastrium,  enteron,  and  colon,  become  disordered, 
deranged  in  relation,  changed  in  situation.  The  flexures  of  the  tractus 
intestinalis  become  more  flexed,  rigid  supports  become  elongaced,  secondary 
supports  are  put  on  tension  and  the  lumen  of  the  tractus  intestinalis  is 
stenosed,  compromised  in  numerous  places.  Canalization  is  compromised. 
The  rigid  ligaments  as  the  ligamentum  hepato-duodenale,  ligamentum  costo- 
colicum,  will  not  yield  as  much  as  the  adjacent  slacker  and  weaker 
ligaments,  hence  the  hepatic  and  splenic  flexures  become  more  and 
more  flexed,  stenosed.  Food  passes  them  with  difficulty.  For  example, 
there  are  5  points  to  consider  in  regard  to  the  fixation  apparatus  of 
the  duodenum,  viz. : 

1.  The  duodenum  is  as  a  whole  fixed.  It  has  lost  its  peritoneal  mesen- 
tery on  both  surfaces  of  the  mesoduodenum  and  its  middle  mesenteric  layer 
(membrana  mesenterii  propria)  is  fixed  or  coalesced  to  the  dorsal  wall.  It 
is  also  fixed  by  the  musculus  suspensorius  duodeni,  and  the  strong  ligament- 
ous band  from  the  left  crus  of  the  diaphragm.  Also  the  head  and  body  of 
the  pancreas  aid  in  fixing  the  duodenum. 

2.  The  pylorus  or  proximal  end  of  the  duodenum  is  fixed  to  the  vertebral 
column,  to  the  liver,  kidney  and  stomach. 

3.  The    flexura    duodenalis  jejunalis  or  distal  end   of   the   duodenum    is, 
especially  fixed  by  musculus  suspensorius  duodeni  and  the  strong  fibrous  and 
ligamentous  band  from  the  left  crus  of  the  diaphragm. 

4.  The  duodenum  being  fixed,  it  can  not  move  distalward,  while  all  the 
other  abdominal  organs  glide  distalward  during  splanchnoptosis.  Hence 
since  the  transverse  segment  of  the  duodenum  becomes  fixed  it  becomes 
compressed  by  the  superior  mesenteric  artery,  vein  and  nerve,  inducing 
gastro-duodenal  dilatation.  The  compression  of  the  duodenum  is  due  to 
the  mesenterico-aortic  (vertebral)  angle  becoming  more  and  more  acute  as 


SPLAXCUXOPTOSIA 


623 


the  splanchnoptosia  progresses,  and  finally,  when  the  enteron  lies  mainly  in 
the  pelvis,  the  mesenterico-vertebral  angle  is  very  acute,  allowing  only  a 
small  space  for  the  duodenum.  The  passing  distalward  of  the  stomach 
stenoses  the  fixed  pylorus,  and  the  passing  distalward  of  the  enteron  makes 
more  and  more  acute  the  flexura  duodeno-jejunalis,  because  the  distal  end 
of  the  duodenum  especially  is  quite  rigidly  fixed.  The  simple  anatomic 
fact  in  splanchnoptosia  is  that  the  proximal  end  of  the  duodenum  is  dilated 
(with  the  stomach).  The  ileo-cecal  sphincter  and  angle  are  not  so  much 
stenosed,  as  both  colon  and  distal  ileum  move  distalward  together,  retaining 
the  normal  angle  or  relations.  The  duodenum  may  be  deranged  by  the 
mobile  right  kidney  through  the  ligamentum  duodcno-renale.     The  dragging 


Fig.  203.  Byron  Robinson's  rubber  air  pad  for  splanchnoptosia  half  dis- 
tended. It  is  to  be  placed  inside  an  abdominal  supporter.  1,  side  of  rubber 
pad  ;  2,  the  rubber  tube  through  which  the  rubber  pad  can  be  distended  with 
air.     (This  rubber  air  pad  is  manufactured  by  John  Drake  &  Co.,  of  Chicago.) 

of  the  dislocated  kidney  aids  to  flex  or  stenose  the  duodenum,  the  retention 
of  foods  in  the  stomach,  and  thus  enhances  gastric  fermentation,  catarrh 
and  dilatation. 


The  Flexura  Colt  Hepatica. 

The  flexura  coli  hepatica  suffers  in  splanchnoptosia,  because  as  the 
stomach  passes  distalward  it  forces  the  colon  transversum  before  it  and  hence 
makes  more  and  more  acute  the  hepatic  flexure.  I  have  seen  the  transverse 
colon  in  the  pelvis  and  9  inches  of  it  as  an  inguinal  hernia.  It  would  at  first 
appear  impossible  for  the  food  to  pass  such  acute  colonic  angles,  but  it  should 
be  remembered  the    peristalsis  is  continued  by  means  of  the  activity  of  local 


624 


THE   ABDOMIXAL   AXD   PELVIC   BRAIX 


segments.  However,  since  the  hepatic  flexure  is  generally  an  obtuse  or  right 
angle,  its  flexure  is  seldom  drawn  so  acutely  by  the  ligamentum  hepatocolicum 
as  to  produce  very  vigorous  stenosis.  Besides,  in  splanchnoptosis  the  liver  yields 
through  its  mesohepar  and  follows  to  some  extent  the  distalward  movements 
of  the  hepatic  flexure,  relieving  its  angle  from  acute  flexing. 

The  Flexura  Coli  Lienalis. 

The  flexura  coli  lienalis  forms  normally  an  acute  angle.  It  is  the  remnant 
of  the  ligamentum  recto-lienalis  of  the  lower  mammals  and  quadrumana.     It  is 

a  distinct,  direct  apparatus  fixing  the  colon 
to  the  costal  wall  and  kidney.  In  splanch- 
noptosia  the  splenic  flexure  is  forced  dis- 
talward and  its  angle  made  more  acute. 
The  spleen  also  participates  in  the  gen- 
eral splanchnoptosis  passing  distalward, 
gliding  ventral  to  the  colon,  as  shown  in 
the  autopsies,  as  far  as  the  pelvic  floor. 
This  increases  the  acuteness  of  the 
colonic  flexure,  obstructing  the  fecal  cur- 
rent. The  stomach  also  forces  the  middle 
of  the  transverse  colon  distalward, which 
stenoses  the  hepatic  and  splenic  colonic 
flexures  in  direct  degree  to  the  extent  of 
the  gastroptosia  (splanchnoptosia). 

Also  the  colon  transversum  in  extensive 
distalward  movements  is  often  forced  into 
a  V-shaped  condition,  with  acute  adjacent 
panetel  flexions  becoming  adherent  by 
plastic  peritoneal  adhesions,  due  to  bac- 
teria or  their  products  passing  through  the 
colonic  mucosa,  myocolon  to  the  serosa, 
resulting  in  peritoneal  exudates  and  or- 
ganized peritoneal  adhesions.  All  dis- 
location of  the  viscera  compromises  them 
in  physiology  and  anatomy  especially  if 
it  be  by  a  progressively  contracting  peri- 
toneal adhesion.  All  dislocation  of  viscera 
compromises  function,  peristalsis,  sensation,  absorption,  secretion — fecal 
blood  and  lymph  circulation  and  traumatizes  nerve  periphery.  Besides, 
splanchnoptosia  is  a  general  term.  The  tractus  intestinalis  and  its  append- 
ages, the  tractus  urinarius,  the  tractus  genitalis,  lymphaticus,  vascularis 
and  nervosus,  all  share  in  the  distalward  movement  due  to  relaxed  walls, 
so  that  splanchnoptosia  of  the  tractus  intestinalis  is  made  worse  by  the 
nephroptosia  (especially  on  the  right  side),  hepatoptosia,  splenoptosia  and 
genital  ptosis.  The  enteroptosia  is  especially  responsible  for  the  gastro- 
duodenal  dilatation,  because  the  duodenum  cannot  pass  distalward  from  a 


Fig.  204.  (Byron  Robinson)  profile 
view  to  illustrate  the  pressure  of  the 
rubber  air  pad  on  the  abdomen.  1,  dis- 
tended pneumatic  rubber  pad;  2,  wall 
of  abdominal  supporter  over  pneumatic 
rubber  pad. 


SPLANCHNOPTOSIA 

definite  fixation  apparatus,  and  the  superior  mesenteric  artery,  vein  and 
nerve — the  constricting  arm — compresses  the  transverse  duodenum  the 
more  acutely  the  more  the  enteronic  loops  pass  distalward  into  the  pelvis. 
Again,  the  distalward  dislocation  of  the  colon  favors  fecal  accumulation, 
which  favors  migration  of  germs  or  their  products  through  mucosa,  muscu- 
laris  into  the  peritoneum,  inducing  plastic  peritoneal  exudates  and  organized 
peritoneal  adhesions.  The  peritoneal  adhesions  compromise  anatomy  and 
physiology  of  the  segments  of  the  tractus  intestinalis.  Again,  a  tractus 
intestinalis  made  defective  by  dislocation  and  fecal  accumulation  becomes  an 
easy  prey  to  muscular  trauma.  Muscular  trauma  of  the  psoas,  for  example, 
makes  over  70  per  cent,  of  the  peritoneal  adhesions  on  the  right  side  (adja- 
cent to  the  appendix,  cecum,  and  distal  ilium),  and  over  80  per  cent,  on  the 
left  side  (in  the  mesosigmoid).  Other  abdominal  muscles  produce  equal 
damage  in  proportion  to  their  power  of  traumatism  by  trauma  of  their  seg- 
ments of  the  tractus  intestinalis.  In  minimum  and  maximum  defect  the 
more  damage  arises  in  the  tractus  intestinalis  from  muscular  trauma  than 
other  visceral  tracts. 

The  fecal  accumulations  produce  maximum  damage  when  collected  in 
the  most  dependent  colonic  segments,  as  the  cecum,  middle  or  transverse 
colon  and  sigmoid;  besides  it  favors  hernia,  invagination  and  volvulus. 
Doubtless  it  is  the  stenosed  and  superior  flexed  splenic  flexures  of  the  colon 
which  produce  the  dull  pain  and  fecal  accumulation  with  dulness  on  percus- 
sion. The  multiple  stenosing  of  various  segments  of  the  tractus  intestinalis 
(and  perhaps  the  ductus  hepaticus)  in  splanchnoptosia  is  of  a  temporary 
character,  because  on  change  of  the  erect  to  the  horizontal  position  the 
stenosis  of  the  tractus  intestinalis  is  damaging  from  the  point  of  circulation, 
nourishment  and  assimilation. 

Splanchnoptosia  induces  trauma  on  secretory,  sensory  and  motor  nerves, 
it  produces  irregular  congestion  and  decongestion,  muscularis  is  impaired  by 
irregular  local  contraction  and  dislocation.  Dislocation  of  the  tractus  intest- 
inalis favors  absorption  of  deleterious  products.  The  relaxed  abdominal  walls 
having  lost  their  power  of  contraction,  the  fecal  current  is  defectively  driven 
distalward.  From  loss  of  tone  in  the  diaphragm,  abdominal  wall  and  pelvic 
floor,  through  excessive  distention,  defecation  is  difficult  and  hence  fecal  and 
gas  accumulations  are  distressing.  Discomfort  almost  always  attends  the 
patient  with  any  considerable  degree  of  splanchnoptosia  from  traumatized 
nerves,  or  from  distension  with  gas  or  food,  from  incapacity  of  the  abdominal 
walls  to  maintain  the  viscera  in  the  normal  physiologic  position.  If  a  subject 
with  distinct  relaxed  abdominal  walls  be  examined  per  vaginum  or  per  rectum, 
stagnated  fecal  accumulation  may  be  found  in  the  sigmoid  and  if  the  cecum 
assume  the  pelvic  position  (female  20  per  cent.,  males  10  per  cent.),  it  may 
also  be  found  occupied  with  feces.  The  abdominal  wall  (thoracic  and  pelvic 
diaphragm)  having  lost  its  tone,  defecation  is  not  only  difficult  but  defect- 
ive. Besides,  long  retained  feces  in  the  colon  induce  catarrh  of  the  colon 
resulting  in  the  absorption  of  toxic  substances.  Mcteorism  arises  in  splanch- 
noptosia from  excessive,  deficient  or  disproportionate  secretion  and  conse- 


62G  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

quent  fermentation,  from  stenosing  of  the  tractus  intestinalis,  from  loss  of 
power  in  the  abdominal  walls,  from  catarrh  due  to  constipation,  from  expan- 
sion of  gas  due  to  rise  of  the  temperature  after  toxic  absorption.  Such 
subjects  have  a  foul-smelling  breath  from  the  gases  being  absorbed  by  the 
veins  in  the  tractus  intestinalis  and  becoming  exhaled  through  the  lungs. 
Meteorism  induces  pain  and  discomfort  from  nerve  pressure,  and  dislocated 
viscera  and  obstruction  to  circulation.  The  results  of  splanchnoptosia  are 
constipation,  catarrh  of  the  different  segments  of  the  tractus  intestinalis, 
icterus  through  pressure,  and  stenosing  of  the  ductus  hepaticus.  Also  the 
nephroptosia  induces  stenosing  of  the  duodenum  and  ureter  by  flexing  and 
rotation. 

Patients  subject  to  splanchnoptosia  suffer  frequently  from  discolored  skin 
and  irregular  kidney  secretion,  also  from  nausea,  vomiting,  irregular  and 
obscure  pains,  with  continual  weakness,  debility.  From  these  anatomic  and 
physiologic  considerations  it  is  amply  evident  that  in  order  to  support  the 
viscera  in  splanchnoptosia  the  thoracic  and  abdominal  walls  (with  pelvic  and 
thoracic  diaphragm)  must  be  forced  into  rational  application. 

In  splanchnoptosia  it  must  be  remembered  that  the  anatomy  thoracic 
and  abdominal  viscera  (tractus  respiratorius,  intestinalis,  vasculoris,  genitalis, 
lymphaticus,  urinarius  nervosus)  is  dislocated  and  that  the  physiology  of  these 
seven  visceral  tracts  is  deranged. 

The  chief  aim  of  therapeutics  in  splanchnoptosia  is  to  restore  function, 
physiology.  We  may  live  comfortable  with  pathologic  anatomy,  however, 
in  general  we  live  in  discomfort  with  pathologic  physiology. 

CIRCULATION  IN  SPLANCHNOPTOSIA. 

In  operating  on  the  deep  glands  of  the  neck,  where  the  large  veins  are 
isolated,  it  is  very  plain  that  respiration  governs  to  a  certain  extent  the 
venous  circulation.  Now,  the  diaphragm,  plevic  and  thoracic,  as  well  as  the 
ventral  abdominal  walls  are  relaxed,  it  becomes  evident  in  difficult  defecation 
and  in  the  same  manner  the  venous  circulation  of  the  abdomen  suffers  from 
lack  of  pressure.  With  relaxed  abdominal  walls,  the  abdominal  veins  (and 
the  entire  system)  are  congested  and  stenosis  results.  As  a  sample  of  the 
evil  effects  of  relaxed  abdominal  walls  and  consequent  splanchnoptosis,  in 
rapidly  repeated  pregnancy  there  is  heart  weakness,  because  the  veins  of  the 
abdomen  are  too  constantly,  excessively  occupied  with  excessive  blood, 
robbing  the  heart  of  its  required  amount.  Since  receiving  instruction  of 
Prof.  Schroder,  some  twenty  years  ago,  I  continued  the  study  and  investiga- 
tion of  splanchnoptosia.  In  relaxed  abdominal  walls  one  sees  the  distended 
veins  of  the  extremities,  and  extensive  and  prominent  veins  of  the  pudenum, 
as  well  as  the  large  hemorrhoidal  nodes.  Besides  frequent  and  free  uterine 
hemorrhages  occur.  Splanchnoptosia  has  deleterious  effect  on  the  pelvic 
organs  by  pressure  and  especially  by  obstructing  the  venous  return  flow.  In 
post  mortems  I  have  carefully  noted  that  subjects  with  splanchnoptosia 
possess  a  plexus  pampiniformis  extended  with  straight,  irregularly  dilated 
veins.     Spiral  and  uniform  calibered  veins  are  normal.    In  advanced  splanch- 


SPLANCHNOPTOSIA 


noptosia  the  pelvic  veins,  especially  the  genitals  and  those  of  the  rectum, 
are  widely  and  irregularly  dilated,  containing  enormous  quantities  of  blood. 
This  causes  hyperaemia,  congestion  and  stasis  of  the  pelvic  organs,  resulting 
in  hemorrhage,  malnutrition,  and  pathologic  changes  in  the  genitals  as  hyper- 
trophy. The  liver  suffers  likewise  from  congestion,  hyperaemia  and  blood 
stasis,  for  it  drains  the  tractus  intestinalis  (spleen  and  pancreas)  and  the 
liver,  by  its  dislocated  position,  compromises  the  blood  current,  especially 
in  the  portal  and  hepatic  veins,  besides,  the  dislocated  liver  drags  or  com- 
presses the  inferior  vena  cava,  stenos- 
ing  it.  Stagnation,  stasis,  congestion, 
hyperaemia  are  the  characteristics  of 
the  circulation  in  the  splanchnoptotic. 
If  the  liver  be  dislocated  to  any  con- 
siderable extent,  which  is  frequent  in 
gynecologic  patients,  the  definite  rela- 
tions of  the  portal  vein  are  disturbed, 
the  liver  veins  and  the  inferior  cava 
are  dislocated  or  compromised,  as  the 
vena  cava  lies  on  the  rigid  dorsal  wall. 
Venous  circulation  is  more  physiologic 
and  of  complex  delicate  nature  than 
arterial,  which  is  more  mechanical,  and 
is  easily  compromised  as  is  noted  by 
the  enlargement,  conspicuously  ob- 
served in  the  inferior  and  superior  epi- 
gastric veins.  Continuous  hyperaemia, 
congestion  and  stenosis  in  the  dislo- 
cated viscera  produces  pathologic 
changes  in  the  organs  themselves, 
impairing  sensation,  motion,  secretion, 
absorption,  and  nutrition.  We  have 
thus  a  vicious  circle  which  might  be 
called  the  visceral  disease.  Relaxed 
abdominal  walls  and  consequent 
splanchnoptosia  disturb  a  wide  area 
of  complicated  functions.  They  distort 
an  extensive  and  delicate  mechanism, 
resulting  in  impaired  respiration,  cir- 
culation, sensation,  motion,  absorption, 
and  secretion  and  in  the  end  result  in  malnutrition  and  neurosis. 

Tension  of  the  visceral  vessels  in  splanchnoptosia  limits  their  lumen  and 
consequently  more  vigorous  heart  action  is  required  to  force  the  blood  to  the 
viscera— taxing  the  heart's  power,  ending  in  anaemia,  congestion,  throbbings, 
headaches,  dizziness.  With  loss  of  the  controlling  influence  of  the  abdominal 
wall  on  the  visceral  circulation  a  fullness  of  feeling  or  weight  in  the  abdomen 
may  occur  from  visceral  congestion  and  continuous  congestion  may  lead  to 
relaxation  of  visceral  supports  occurring  in  splanchnoptosia. 


Fig.  205.  Byron  Robinson's  pneumatic 
rubber  air  pad  is  fitted  to  the  abdomen  inside 
the  abdominal  supporter.  2,  3  are  rubber 
tubes  passing  between  the  limbs  to  fix  the 
abdominal  supporter.  It  requires  several 
days,  a  week  for  patients  to  become  ad- 
justed to  the  pad.  Patience  on  the  part  of 
the  patient  and  encouragement  on  part  of 
the  physician  will  soon  adjust  the  use  of 
the  pad. 


628  THE  ABDOMINAL  AND  PELVIC  BRAIN 

In  splanchnoptosia  the  visceral  circulation  is  impeded  by  flexion,  dilata- 
tion, constriction,  decalibration,  elongation,  of  vessels  (and  the  accompany- 
ing plexiform  nerve  sheath  is  consequently  traumatized).  In  splanch- 
noptosia the  veins  from  thin,  flaccid  walls,  deficient  muscularis  and  slow 
pressure  current  suffer  more  than  the  arteries  which  possess  rigid  walls, 
powerful  muscularis  and  vigorous  high  pressure  current.  Atonia  gastrica  is 
responsible  for  two  important  phenomena  of  visceral  vessels,  viz. :  (a)  flexion 
or  angulation ;  (b)  elongation  and  consequent  decrease  in  lumen,  decalibra- 
tion. Conspicuous  examples  of  flexion  or  angulation  of  vessels  may  be 
observed  in  extensively  distalward  movements  of  the  kidney  which  is  fre- 
quently located  in  the  middle  of  the  abdomen  on  the  pelvic  brim  and  the 
spleen  which  is  not  infrequently  found  located  at  any  point  from  the  kidney 
to  the  pelvic  floor.  The  distalward  dragging  of  the  viscera  at  different  points 
on  the  visceral  ligaments  fixed  to  the  abdominal  wall  flexes  or  angulates  the 
vessels  in  extra-extended  ligaments  producing  hyperaemia  or  anaemia, 
engorgement  or  ischaemia.  If  one  explores  by  dissection  the  abdominal 
visceral  vessels  in  a  normal  subject  and  again  in  a  splanchnoptotic  subject  by 
comparison  it  will  be  observed  that  the  visceral  vessels  of  the  splanchnoptotic 
may  be  several  inches  longer  than  those  of  the  normal  subject,  e.  g.,  when 
the  kidney  lies  in  the  iliac  fossa  or  lesser  pelvis,  when  the  spleen  lies  on 
the  pelvic  floor,  when  the  enteron  lies  almost  completely  on  the  pelvic  floor. 

The  visceral  vessels  become  elongated  in  splanchnoptosia  and  elongation 
compromises  the  canals  and  lumen  of  the  vessels,  limiting  vascular  supply, 
inviting  defective  viscera,  resulting  in  innervation,  constipation,  deficient 
secretion,  limited  and  disordered  peristalsis.  In  enteroptosia  the  superior 
mesenteric  artery  and  vein  is  the  one  set  of  vessels  which  suffers  from  drag- 
ging, trauma,  from  marked  elongation  of  parietes  and  constriction  of  lumen. 
The  elongated  superior  mesenteric  artery,  vein  and  nerve  constricts,  stenoses 
the  transverse  segment  of  the  duodenum  by  compression.  Thus  in  splanch- 
noptosia one  distorted  viscus  compromises  another.  It  may  be  observed  that 
the  visceral  vessels  are  compelled  to  elongate  in  splanchnoptosia  as  their 
base  or  origin,  the  aorta,  is  immobile.  In  gestation  the  utero-ovarian  artery 
elongates,  experiences  parietal  hypertrophy,  increases  its  spirality  and 
diameter  of  its  lumen.  However,  gestation  practically  cures,  symptomat- 
ically  relieves  splanchnoptosia  for  some  six  months.  In  splanchnoptosia 
practically  the  opposite  condition  to  that  of  the  arteria  uterina  ovarica  in 
gestation  occurs  in  the  visceral  arteries,  viz. :  the  visceral  arteries  elongate, 
decrease  in  diameter,  diminish  in  spirality,  experience  parietal  atrophy. 
Finally  during  the  elongation  of  visceral  vessels  vast  sympathetic  nerve 
trauma  is  inflicted  on  the  plexiform,  nodular  network  of  nerves  which 
ensheath  the  visceral  vessels,  damaging  vascular  function  (especially  rhythm) 
for  the  tractus  vascularis  and  tractus  nervosus  is  an  automaton.  Hence, 
from  the  dragging  of  the  viscera  on  their  elongated  tensioned  vessels,  from 
vessel  extension,  flexion  and  trauma  on  associated  ganglia,  excessive,  deficient, 
or  disproportionate  circulation  arises.  In  splanchnoptosia  palpatation, 
vigorous  beating  in  the  abdominal  aorta  which  may  be  palpated  from  partial 


SPLANCHNOPTOSIA  629 

uncovering  or  exposure  of  the  aorta  by  dislocated  viscera  and  atrophy  of  the 
abdominal  wall.  The  arterial  pulse  beat  is  disordered — irregular,  deficient, 
excessive.  Splanchnoptoses  are  afflicted  frequently  with  debility,  impend- 
ing weakness,  faint  with  facility  and  present  rapid,  variegated  changes  in 
circulation  in  different  parts  of  the  body.  The  patient  is  flushed  (conges- 
tion), pale  (anaemic),  mottled  (disproportionate  circulation).  They  have 
headaches  from  irregular  cerebral  circulation  and  extensive  abdominal 
venous  stasis.  In  autopsies  on  some  advanced  splanchnoptoses  the 
numerous  vastly  distended  blue  veins  presenting  among  the  abdominal 
viscera  suggest  the  idea  that  the  patient  had  bled  to  death  in  his  own 
abdominal  veins.  The  veins  of  the  viscera  and  ganglia  are  engorged,  flooded 
with  stagnant  venous  blood  surcharged  with  carbonic  acid  gas — while  the 
arterial  blood  invigorated  with  life's  messenger,  oxygen,  is  excluded. 

The  similar  conditions  as  regards  haemogenous  circulation  in  splanchno- 
ptosia  may  be  practically  applied  to  the  lymphatic  circulation  in  splanch- 
noptosia. 

The  abdominal  walls  aid  to  regulate  the  circulation  in  the  viscera 
(especially  in  the  veins).  The  abdominal  vessels  (veins)  are  a  kind  of 
reservoir  for  surplus  blood  by  which  blood  pressure  and  other  visceral  supply 
is  regulated.  If  the  abdominal  muscles  become  deficient  the  blood  will 
accumulate  in  the  abdominal  veins  to  the  detriment  of  other  viscera,  e.  g., 
the  cerbro-spinal  axis — manifesting  many  nervous  phenomena.  The  exten- 
sive venous  stasis  in  the  abdomen  from  atonia  gastrica  deranges  visceral 
function  (peristalsis,  absorption,  secretion,  sensation)  ending  in  malassimila- 
tion  (indigestion,  fermentation,  meteorism,  constipation).  The  meteorism  so 
frequent  an  accompaniment  of  the  splanchnoptotic  is  a  marked  factor  in 
disturbing  circulation  and  digestion.  In  the  splanchnoptotic  the  dilatation 
of  the  blood  vessels  in  the  splanchnic  area  may  lead  to  a  decrease  in  general 
blood  pressure  and  consequent  increase  of  cardiac  action.  The  symptoms 
due  to  the  pathologic  physiology  of  circulation  in  the  abdominal  vessels  are 
varied  and  numerous  as  rate,  nature,  force  cf  peristalsis  in  the  heart,  and 
consequent  effect  on  the  abdominal  viscera.  The  extent  of  distention  of  the 
abdominal  vessels  would  no  doubt  produce  pathologic  manifestations  as 
dragging,  feeling  of  fulness,  weight.  Long  continued  congestion  due  to 
vaso-motor  paralysis  (from  lack  of  abdominal  pressure)  may  account  for 
relaxation  of  visceral  supports.  The  manipulation  of  the  plexiform  nodular 
network  ensheathing  the  arteries  may  be  followed  by  palpation  and  be  found 
tender,  sensitive — indicating  an  irritable  condition  of  the  blood  vessels, 
arteritis,  arterio-sclerosis,  or  a  neuritis  of  the  ensheathing  nerve  plexus 
(which  is  the  more  probable). 

Dilatation  of  the  splanchnic  vessels  appear  to  be  physiologically  opposed 
to  a  similar  condition  of  the  peripheral  vessels  and  the  exquisite  balance  is 
due  to  a  nerve  mechanism.  Our  remedies  should  be  applied  with  2  views, 
viz. :  (a),  to  deplete  the  visceral  congestion.  This  can  be  especially  accom- 
plished by  visceral  drainage  and  aided  by  mechanical  supports,  the  abdomi- 
nal wall  which  regulates  venous  circulation  (as  by  binders,  Rose's  strapping); 


630  THE  ABDOMINAL  AXD  PELVIC  BRAIN 

(b),  stimulate  the  peripheral  or  cutaneous  vessels  (by  friction  heat,  chemicals) 
in  order  to  entice  the  blood  to  the  surface  (as  massage,  salt  rubs,  hydro- 
therapy, wet  cold  pack). 

TRACTUS    NERVOSUS  IN  SPLANCHNOPTOSIA. 

The  ideal  nervous  system  consists  of:  (a)  a  ganglion  cell  (a  central 
receiver  and  reorganizer),  (b)  a  conducting  cord  (a  transmitter),  (c)  a  peri- 
phery (a  sensory  apparatus,  a  collector).  In  splanchnoptosia  the  ideal 
nervous  apparatus  is  deranged.  I  am^convinced  from  years  of  observation — 
in  the  living  and  dead — that  the  tractus  nervosus  in  splanchnoptosia  indicates 
inferior  anatomy  and  physiology  with  more  facility  than  other  visceral  tracts. 
Splanchnoptotics  are  prone  to  be  afflicted  with  stigmata,  degeneracy,  a  habi- 
tus. They  possess  a  weak,  irritable  nervous  system.  They  are  not  perfect 
physically  or  mentally.  Their  anatomy  and  physiology  are  inferior  structure 
and  function  of  minimum  perfection.  The  nervous  system  is  unstable. 
Splanchnoptotics  manifest  defective  resistance,  and  are  incapacitated  for 
sustained  effort,  presenting  premature  exhaustion  on  persistence  mentally  or 
physically.  Their  tractus  nervosus  functionates  under  friction  most  of  the 
time  like  some  watches  which  maintain  incorrect  time.  Splanchnoptotics  are 
chiefly  congenital,  physical  unfortunates.  They  are  born  with  defects,  stig- 
mata, a  habitus,  a  neuropathic  predisposition — a  condition  or  state  which 
tends  to  degeneracy  with  facility.  One  of  the  best  terms  to  apply  to  subjects 
with  excessive  distalward  movement  of  viscera,  relaxed  muscles,  defective 
circulation,  and  defective  nourishment  is  the  word  habitus,  e.  g.,  we  meet 
the  subjects  with  habitus  splanchnopticus,  habitus  nervosus,  habitus 
phthisicus,  habitus  dyspepticus.  The  ensemble  of  symptoms  associated  with 
splanchnoptosia  may  well  be  termed  habitus  splanchnopticus.  It  is  heredity 
in  so  far  that  the  subject  possesses  a  predisposition  and  the  main  defect  is 
inferior  anatomy  and  physiology.  In  the  habitus  splanchnopticus  there  is 
the  gracile  skeleton,  the  elongated,  flat  thorax,  extensive  intercostal  space, 
acute  epigastric  angle,  the  sacculated  pendulous  abdomen,  limited  muscularis 
and  panniculus  adiposus,  the  labored  respiration.  The  costa  fluctuans  dec- 
ima  of  B.  Stiller,  the  peculiar  habitus  in  form— presenting  evident  patho- 
logic physiology.  A  marked  factor  in  pathologic  physiology  of  splanchnop- 
tosia is  the  changed  defective  circulation,  venous  congestion.  Generally  any 
subject  with  a  '"habitus"  possesses  an  unstable  nervous  system.  The  habitus 
splanchnopticus  is  perhaps  more  due  to  neuropathic  disposition  than  to 
the  splanchnoptosia,  hence  the  term  dyspepsia  nervosa,  or  stigma  dys- 
pepticus. The  habitus  neurasthenicus  presents  pathologic  physiology  of  the 
tractus  nervosus — a  condition  of  exhaustion  or  weakness  of  the  nervous 
system  accompanied  by  physical  and  mental  inefficiency.  Habitus  neuras- 
thenicus is  a  fatigue  disease  of  the  nervous  system.  It  is  characterized  by  the 
presence  of  motor,  sensory,  psychic  and  visceral  symptoms — all  fatigued, 
tired,  exhausted.  This  habitus  is  especially  characterized  by  weakness,  or 
inefficiency  and  irritability  of  the  tractus  nervosus.  The  physician  can  detect 
spots,    of    hyperesthesia,    spinal   irritation,    fatigue    of    the    special    sense, 


SPLANCHNOPTOSIA  i;;;i 

auditory  and  retinal  hyperesthesia.  When  the  subject  predisposed  to  the 
habitus  splanchnopticus  is  afflicted  with  strain,  as  gestation,  the  care  of 
growing  children,  extra  mental  or  physical  effort,  the  tractus  nervosus — 
habitus  neurasthenicus — manifests  itself  deranged  with  rapidity  and  facility. 
Also  the  instability  of  the  tractus  nervosus  in  splanchnoptosia  is  aggra- 
vated, irritated  with  facility  in  the  habitus  neurasthenicus  by  disease,  as 
salpingitis,  myometritus,  pelvic  peritonitis.  The  weak,  irritable  tractus 
nervosus  with  its  inherent  defective  vital  power — its  deteriorated  anatomy 
and  physiology — readily  passes  into  a  state  of  manifest  pathologic  physiology. 
In  splanchnoptosia  the  nervous  system  is  involved  in  manifold  conditions. 
In  fact,  in  splanchnoptosia  the  nervous  system  is  the  central  reference  of  in- 
vestigators. Hence,  writers  note  that  splanchnoptoses  are  afflicted  with  mel- 
ancholia neurasthenia,  nervous  dyspepsia,  neurosis,  irritability,  weakness  and 
debility.  The  splanchnoptotic  experiences  pain  of  various  kinds  in  any  por- 
tion of  the  abdomen.  They  are  afflicted  with  heavy  feelings  in  the  abdomen. 
Pain  radiates  to  the  scapulae, especially  in  the  region  of  the  V  to  the  VII  dorsal 
vertebrae.  The  pain  is  increased  in  the  erect  and  decreased  in  the  prone 
attitude  (indicating  nerve  trauma).  Continuous  standing,  long  labor  or  severe 
efforts  increase  the  pain.  The  multiple  pain  of  the  splanchnoptotic  is 
described  as  dull,  sticking,  dragging,  boring,  cramps,  faintness,  lumbar  and 
sacral  pains.  Some  have  pain  in  many  parts  of  the  body.  The  sensible 
visceral  nerves  and  ganglia  become  traumatized,  dragged  by  the  dislocated 
viscera.  The  visceral  arteries  are  ensheathed  by  a  ganglionated,  plexiform 
network  of  nerves.  In  splanchnoptoses  the  visceral  arteries  become  elon- 
gated (sometimes  several  inches,  in  extra  length)  and  their  ensheathing 
nerves  stretched,  damaged,  traumatized,  altering  their  functions.  The  pain 
is  protean.  Hegar  called  it  Lendenmarks  symptome,  i.  e.,  lumbar  cord  symp- 
toms. The  dislocated  viscera  drag  on  the  great  plexuses,  resulting  in  irri- 
tability. Hyperesthesia  and  anaesthesia  of  the  abdomen  exist  over  the 
site  of  viscera— which  suggests  caution  in  pronouncing  the  stigmata  of 
hysteria.  The  plexus  aorticus  is  frequently  so  stimulated  that  the  vigorous, 
violent  aortic  pulsations  may  be  mistaken  for  an  aneurysm.  When  no 
anatomic  or  histologic  changes  in  the  nerves  can  be  demonstrated  we  are  com- 
pelled to  resort  to  such  terms  as  neurosis,  molecular  disturbances  in  the  nerve 
substance  or  peripheral.  Is  splanchnoptosia  due  to  a  relaxation  of  the  entire 
nervous  system?  Splanchnoptosia  attacks  the  motor  nerves  as  it  is  shown  by 
muscular  fatigue,  energy.  Evident  incapacity  for  bodily  labors  present. 
The  sensory  nerves  may  suffer  in  splanchnoptosia  as  in  anaesthesia  and  para- 
aesthesia.  The  patient  is  sensitive  to  heat  and  cold.  Exaltation  and  depres- 
sion occur.  The  sympathetic  nerve  or  nervus  vasomotorius  receives  the 
brunt  of  the  disease  as  is  manifest  in  disturbed  secretion,  absorption,  sensa- 
tion and  rhythm  (peristalsis)  of  viscera.  Violent  aortic  palpation  of  the 
aorta  exists.  Secretion,  absorption  and  peristalsis  may  be  excessive,  deficient 
or  disproportionate. 


632  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

Frequency  of  SplancJinoptosia. 

In  the  vast  majority  of  splanchnoptoses  in  general  the  viscera  are  dis- 
placed, prolapsed,  and  the  visceral  walls  relaxed.  Splanchnoptosia  is  perhaps 
six  times  more  prevalent  in  females  than  in  males  (some  say  ten).  I  have  no 
method  to  estimate  the  frequency  of  splanchnoptosia  in  my  own  practice  ex- 
cept from  the  frequency  of  mobile  kidney  and  in  the  personal  autopsic 
abdominal  inspection  of  over  650  adults  and  75  children,  infants,  fetuses.  60% 
of  the  female  patients  in  my  practice  present  palpably  mobile  kidney,  not 
splanchnoptosia,  as  no  pathologic  symptoms  accompany  many.  The  diffi- 
culty of  estimating  the  frequency  of  splanchnoptosia  is  due — and  also  the 
conditions  of  splanchnoptosia  which  present  symptoms — to  the  different  views 
of  different  authors.  I  should  estimate  that  20%  of  the  women  with  mobile 
kidney,  in  my  private  practice,  have  demonstrable  splanchnoptosia — with 
attributable  symptoms  (i.  e.,  20%  of  60%  =12%).  Part  of  this  20%,  say  12%, 
do  not  suffer  markedly,  for  in  many  the  physical  condition  remains  favorable. 
Practically  twenty  years  includes  the  clinical  and  autopsic  study  of  splanch- 
noptosia, hence,  older  statistics  are  almost  worthless.  Twenty  years  ago  Mr. 
Lawson  Tait,  one  of  the  greatest  surgical  geniuses  of  his  age,  and  my  own 
well-remembered  teacher,  denied  movable  kidneys.  The  difficulty  with  sta- 
tistics in  splanchnoptosia  is  that  it  presents  a  wide  range  from  the  minimum 
scarcely  perceptible  to  the  maximum  grade — an  unsightly,  sad  appearance. 
Hence  we  still  lack  a  recognized  standard  to  estimate  the  frequency  of 
splanchnoptosia. 

Symptomatology  of   SplancJinoptosia. 

Splanchnoptosia  presents  complex  symptoms.  It  may  exist  without 
recognizable  symptoms  or  be  accompanied  by  the  most  aggravated  kind. 
The  general  subjective  symptoms  of  splanchnoptosia  are  (debility)  a  general 
sense  of  weakness;  an  impending  irritable  nervousness  (neurosis),  frequent  re- 
lief in  the  prone  position  (attitude).  Practically,  splanchnoptosia  should  be 
viewed  as  pathologic  physiology,  as  a  disease  of  symptoms  and  the  object  of 
the  physician  is  to  restore  function.  Fatigue  and  pain  are  marked.  The  gen-, 
eral  objective  symptoms  are:  (abdomen)  flattened  pendulous  abdomen 
especially  in  the  epigastric  region  (Stellar's  costalstigma),  sensitiveness  to 
pressure  in  the  region  of  the  tenth  rib,  palpation  reveals  excessive,  multiple, 
visceral  mobility.  A  cord-like  transverse  colon  (which  is  probably  the  pan- 
creas) may  be  established  by  gliding  it  on  the  aorta.  A  marked  pulsation  of 
the  aorta,  constipation.  A  peculiar  phenomenon  may  exist  in  splanchnop- 
tosia which  is  in  short  that  the  intensity  of  the  symptoms  may  not  correspond 
to  the  degree  of  splanchnoptosia.  This  doubtless  depends  on  favorable  or 
unfavorable  physical  conditions.  Marked  splanchnoptosia  may  exist  with 
practically  no  symptoms  while  a  slight  degree  of  splanchnoptosia  may  exist 
accompanied  with  striking  symptoms.  Frequently  the  visceral  ptosis  is  so 
slight  that  it  is  overlooked  and  consequently  the  treatment  is  misapplied. 
An  important  matter  in  atonia  gastrica,  splanchnoptosia,  is  that  symptoms  are 
pronounced  while  the  patient  is  in  the  erect  attitude.     With  the  patient  lying 


SPLANCHNOPTOSIA  633 

prone  the  symptoms  diminish  and  may  disappear.  This  phenomenon  deludes 
many  physicians  who  consider  merely  that  the  patient  requires  physical  rest. 
Frequently  I  have  noted  immediate  relief  by  supporting  the  abdomen  with 
the  hands  from  behind  the  patient  (Glenard's  belt  test).  Besides  the  ordinary 
symptoms  of  fatigue,  dragging,  there  is  backache  and  side  ache  The  back- 
ache in  splanchnoptosia  may  be  due  to  fatigue  of  the  sacro-spinalis  muscle 
simulating  that  observed  in  corpulent  persons  with  fatty  abdomen  where 
the  muscle  becomes  overworked  in  maintaining  the  center  of  gravity  which 
is  projected  excessively  ventralward.  In  respiration  in  splanchnoptotics  the 
expiratory  power  is  not  only  lessened  by  loss  of  tone  in  the  abdominal  mus- 
cles but  the  floor  of  the  thorax,  the  diaphragm,  is  dragged  distalward  by  the 
distalward  moving  viscera.  The  epigastrium  may  show  a  marked  depression. 
The  relation  of  the  diaphragm  and  ribs  is  disturbed,  inducing  shortness  of 
breath  on  exertion.  To  observe  the  splanchnoptotic  one  must  examine  in 
the  prone  and  erect  attitude  with  trunk  clothing  removed.  The  patients  fre- 
quently complain  of  weakness,  dizziness,  fatigue  which  may  be  enhanced  by 
the  distalward  moving  viscera  dragging,  traumatizing  the  splanchnic  (sympa- 
thetic) nerves.  Most  cases  of  splanchnoptosia  are  accompanied  by  pendulous 
abdomen,  changed  in  form,  however,  with  normal  abdominal  walls  a  single 
viscus  may  glide  excessively  distalward  while  mechanical  pendulous  abdomen 
ma}'  be  caused  by  fat  deposit.  Splanchnoptosia  may  exist  without  symp- 
toms so  long  as  the  physical  condition  is  favorable.  Atonia  gastrica  springs 
into  prominence  in  association  with  neurosis  and  so-called  nervous  dyspepsia. 
The  symptoms  of  the  splanchnoptotic  are  chiefly  those  of  neurasthenia, 
neurosis.  Pain  may  be  felt  and  is  mainly  referred  to  the  lateral  and  dorsal 
region.  Splanchnoptosia  is  practically  a  unit  though  a  general  disease, 
seldom  do  single  viscera  suffer  ptosis.  Exception  may  arise  from  sudden 
trauma,  for  example,  instrumental  parturition,  sudden  physical  strain. 
However,  the  ordinary  case  of  recognizable  splanchnoptosia,  atonia  gastrica, 
is  general  visceral  ptosis  with  relaxed  enclosing  walls.  Splanchnoptosia  must 
not  be  judged  by  the  extent  of  dislocated  viscera  but  by  the  degree  of  dis- 
tress— the  intensity  of  symptoms,  the  pathologic  physiology.  The  distalward 
dislocation  of  the  diaphragm  is  an  essential  feature  of  splanchnoptosia. 
Hence  in  marked  subjects  of  splanchnoptosia  the  chest  is  deformed,  the 
thoracic  viscera  occupy  abnormal  positions  and  the  abdominal  viscera  are 
splanchnoptotic — the  subject  generally  presents  stigmata,  physical  defects, 
tubercular  habitus,  deformed  distal  thoracic  borders.  A  study  of  the  sub- 
ject of  splanchnoptosia  has  exposed  many  previous  puzzles.  A  faint  feeling 
after  the  morning  rising,  fatigue  after  exercise  sense  of  weight  in  distal  and 
dorsal  abdomen,  dragging  in  epigastrium,  flatulence,  constipation,  frequent 
micturition,  lends  clues  to  widespread  splanchnoptosia.  Neurasthenia,  flaccid 
and  pendulous  abdomen,  loss  of  flesh,  diastasis  of  the  recti  muscles  shed  light. 
The  aorta  frequently  strongly  pulsates,  and  with  spare  subjects  one  feels 
what  Glenard  calls  the  "transverse  colon  cord,"  however,  I  am  fully  satisfied 
at  present  after  investigating  these  symptoms  frequently  in  autopsies  that 
this  transverse  band  or  "colon  cord"  is  the  pancreas  mainly. 


634  THE  ABDOMLXAL  AXD  PELVIC    BRAIN 

General  Symptoms. 

Writers  continually  associate  splanchnoptosia  and  nervous  dyspepsia. 
It  seems  to  me  such  terms  as  nervous  dyspepsia  should  be  abandoned  because 
later  investigations  have  demonstrated  that  the  various  symptoms  of  splanch- 
noptosia are  practically  due  to  the  malposition  and  consequent  pathologic 
physiology  of  viscera.  In  marked  subjects  of  splanchnoptosia  the  symptoms 
of  degeneracy  present  as  B.  Stillar's  floating  tenth  rib  (decima  costa  fluc- 
tuans)  neurasthenia,  so-called  nervous  dyspepsia. 

Splanchnoptotics  may  improve  with  advancing  senescence.  This  must 
mean  that  the  neurosis  and  so-called  nervous  dyspepsia  improves — not  the 
splanchnoptosia  for  splanchnoptosia  practically  increases  with  senescence, 
that  is  after  35.  The  explanation  must  lie  in  the  adjustment  and  compen- 
satory action  of  the  splanchnoptotic  organs.  The  anatomy  and  physiology 
of  the  dislocated  organs  has  become  used  to  the  order  of  things.  Meinert 
has  written  extensively  on  the  relation  of  chlorosis  and  splanchnoptosia. 
It  is  more  probable  that  the  relations  of  chlorosis  and  splanchnoptosia  are 
distant  and  rather  that  the  defective  constitutional  power  exposes  the  subject 
to  both  splanchnoptosia  and  clorosis — congenital  and  acquired  defects 
which  favor  both  diseases. 

The  symptoms  of  splanchnoptosia  are  distension,  expansion  of  thoracic 
and  abdominal  walls.  The  thoracic  and  abdominal  viscera  are  dislocated, 
succulated,  flexed.  The  visceral  function  (peristalsis,  absorption,  secretion, 
sensation)  are  disturbed. 

The  symptoms  of  splanchnoptosia  are  functional,  physiologic  disturban- 
ces rather  than  definite  marked  anatomic  or  pathologic  anatomy  lesions. 
The  major  visceral  functions  sensation,  peristalsis,  absorption,  secretion  are 
deranged.  The  visceral  tracts,  viz. : — Respiratory,  circulatory,  digestive, 
urinary,  genital,  nervous  are  compromised  in  physiology  and  anatomy. 
Pathology  is  evident  chiefly  in  pathologic  physiology  only. 

GENERAL   TREATMENT   OF   SPLANCHNOPTOSIA. 

The  treatment  should  be  medical,  mechanical,  surgical. 
/.     Medical  Treatment. 

The  essentials  of  medical  treatment  in  splanchnoptosia  are:  (1),  hygiene; 
(2),  visceral  drainage;  (3),  diet;  (4),  habitat;  (5),  avocation,  electricity, 
spray,  douche.  Advice  is  frequently  of  more  value  to  a  splanchnoptotic  than 
medicine. 

Splanchnoptosia  is  practically  a  medical  disease  belonging  to  the  inter- 
nist. The  physician  should  treat  not  merely  single  organs  but  the  patient. 
Symptoms  of  general  splanchnoptosia  and  neurosis  should  not  be  attributed 
to  single  dislocated  organs  as  nephroptosia,  hepatoptosia  gastroptosia.  The 
subjective  difficulties  should  be  treated  and  not  merely  the  clinical  findings, 
because  the  patient  may  be  suffering  more  severely  than  the  physical  findings 
indicate.  In  splanchnoptosia  the  chief  treatment  consists  in  correcting  the 
pathologic  physiology  of  the  thoracic  and  abdominal  viscera  as  well  as  the 


SPLANCHNOPTOSIA  635 

restoration  of  the  strength,  firmness  and  elasticity  of  the  enclosing  walls. 
Unfortunately  the  restoration  of  elasticity,  of  excessively  extended  muscle 
and  connective  tissue  is  difficult.  The  aim  of  the  physician  should  be  restor- 
ation of  function.  In  splanchnoptosia  there  are  four  grand  factors  to  con- 
sider; viz.:  (a)  relaxation  of  the  thoracic  and  abdominal  walls,  (b)  distalward 
movements  of  contained  viscera  (splanchnoptosia)  (c)  gastro-duodenal 
dilatation,  (d)  change  of  form  of  thorax,  (flared),  and  abdomen  (pendulous). 
On  these  basic  factors  will  rest  the  rock  and  base  of  our  plans  in  treatment. 

(/)     Hygiene. 
Hygiene  has  reference  to  the  method  of  living,  the  quantity  and  quality 
of  ingested  fluid  and  food,  the  exercise  of  functions,  the  quantity  and  quality 
of  fresh  air  employed  and  the  relations  of  environments.     In  hygiene  the 
advice  of  a  physician  is  frequently  more  useful  than  drugs. 

(2)      Visceral  Drainage. 

The  splanchnoptotic  suffers  almost  continually  from  pathologic  physi- 
ology and  the  chief  medical  treatment  consists  in  correcting  diseased  visceral 
physiology  or  function.  For  the  splanchnoptotic  the  most  important 
treatment  from  beginning  to  end  is  ample  visceral  drainage.  The  best 
diuretic  is  H20.  The  sovereign  visceral  drainage  fluid  is  different  grades  of 
physiologic  salt  solution.  I  administer  8  ounces  of  ^2  to  %  physiologic 
salt  solution  before  each  meal  (better  hot)  and  between  meals,  i.  e.,  the 
subject  drinks  8  ounces  of  lA  to  Y\  physiologic  salt  solution  every  2  hours 
or  3  pints  daily  regardless  of  other  fluids.  (Note — sodium  chloride  should 
not  be  administered  to  subjects  afflicted  with  parenchymatous  nephritis.) 

The  sodium  chloride  stimulates  the  epithelium  of  the  tractus  urinarius 
and  tractus  intestinalis.  In  addition  to  the  physiologic  salt  solution  I 
administer  on  the  tongue  at  the  same  time  a  part  or  multiple  of  an  alkaline 
tablet  (composed  of:  Cascara  sagrada,  one-fortieth  of  a  grain;  aloes,  one- 
third  of  grain;  NaHC03,  one  grain;  KHCO3,  one-half  grain;  MgS04  2grain.) 
The  sodium  chloride  tablet  contains  11  grains.  The  combined  treatment 
consists  in  placing  (J  to  2)  alkaline  tablets  as  required  to  produce  one  bowel 
movement  daily  and  {Vz  to  Y\)  sodium  chloride  tablet  on  the  tongue  (every 
two  hours)  followed  immediately  by  a  half  a  pint  of  HaO  6  times  daily. 
The  plan  of  treatment  I  term  the  "visceral  drainage"  treatment,  continuing 
it  for  weeks,  months  and  the  results  are  remarkably  successful.  The  urine 
becomes  clarified  resembling  spring  water  and  increased  in  quantity.  The 
tractus  intestinalis  becomes  amply  evacuated  regularly  daily.  The  blood  is 
drained  of  waste  material.  The  tractus  cutis  eliminates  freely,  and  the 
skin  becomes  normal.  The  appetite  increases.  The  sleep  becomes  improved. 
The  feelings  become  more  hopeful.  The  sewers  of  the  body  are  vigorously 
drained  and  flushed.  The  greatest  principle  in  medicine  and  surgery — 
drainage — is  accomplished. 

(j)     Diet. 

The  diet  influences  visceral  function  equally  with  fluids,  the  main  ideal 
of  diet  for  the  splanchnoptotic  is  that  it  shall  be  coarse,  voluminous,  and 


THE  ABDOMIXAL   AXD   PELVIC  BRAIX 

result  in  ample,  indigestible  faecal  residue  in  order  to  stimulate  the 
functions  of  the  tractus  intestinalis  (peristalsis,  absorption,  secretion,  sensa- 
tion). The  kinds  of  foods  for  the  splanchnoptotic  should  be  (a)  cereals 
(oatmeal,  prepared  wheat,  rice,  graham  bread — i.  e.,  the  entire  wheat  as 
bran,  shorts,  and  flour),  (b)  vegetables  (cooked),  (c)  albuminoids  (milk, 
eggs),  (d)  meats  (limited  in  quantity).  Diet  should  be  strictly  regulated. 
Food  should  be  administered  every  three  hours  in  limited  quantities.  All 
fermentative  substances  should  be  avoided.  Fruits  unless  strictly  regulated 
do  more  harm  than  good  (from  fermentative  processes).  Pies,  puddings, 
cakes,  sugars,  sauces,  and  condiments  should  be  prohibited.  Diet  should 
be  wholesome  and  nutritive  to  produce  fat  for  visceral  padding  whence  the 
visceral  shelves  and  fossae  are  increased  and  the  abdominal  wall  thickened 
enabling  it  to  diminish  the  abdominal  cavity  to  aid  in  visceral  reposition  and 
maintenance  in  the  normal  physiologic  position.  One  of  the  essential 
pathologic  conditions  in  splanchnoptosia  is  malnutrition,  inanition.  Splanch- 
noptosia  is  best  cured  by  rebuilding  the  organism  which  signifies  normal 
blood  and  panniculus  adiposus.  The  practical  therapeutics  in  splanchno- 
ptosia is  to  improve  the  pathologic  physiology,  for  splanchnoptotics  live 
continually  under  pathologic  physiology.  The  visceral  drainage  treatment 
improves  health.  It  places  visceral  function  and  elimination  at  a  maximum. 
Hence,  the  subject  is  better  prepared  to  institute  local  repair  which  means 
resisting  and  checking  infection,  absorbing  exudates.  The  visceral  drainage 
treatment  can  be  conducted  at  the  patient's  home,  be  it  a  cottage  or  a  palace, 
without  cessation  of  his  occupation.  There  is  no  necessity  of  making  long 
sojourns  to  distant  watering  places  to  drink  hissing  sprudel  or  odorous 
mineral  waters. 

(./).     Habitat. 

Habitat  or  the  environments  of  life  are  significant  in  the  general  treat- 
ment of  the  splanchnoptotic.  First  and  foremost,  the  splanchnoptotic  should 
have  ample  fresh  air  night  and  day.  The  window  should  be  open  all  night 
summer  and  winter.  Clothing  should  be  suspended  from  the  shoulder  avoid- 
ing all  tight  waist  bands.  Physical  exercise  should  be  regular  and  practiced 
daily. 

(5).     Avocation. 

The  business  or  association  of  a  splanchnoptotic  is  a  matter  of  importance 
as  he  is  unable  mentally  or  physically  to  withstand  persistent  continued  effort. 
Mental  and  physical  rest  is  necessary  for  the  subject  afflicted  with  inferior 
anatomy  and  inferior  physiology.  Heavy  labor  he  cannot  endure.  Constant 
standing  on  the  feet  for  hours  exhausts  the  splanchnoptotic.  He  should 
assume  a  horizontal  position  frequently  in  order  to  change  the  circulation 
and  rest  the  fatigued  muscles.  Assuming  frequent  physical  rests  the  splanch- 
noptoses inferior  physiologic  functions  and  inferior  anatomic  structures 
may  maintain  fair  health  and  accomplish  a  reasonable  degree  of  labor. 


SPLANCHNOPTOSIA  637 

(tf).     Electricity. 

Electricity  is  of  considerable  value  in  relaxed  abdominal  walls,  especially 
faradization  of  the  muscles. 

(r).      The  Cold  Douche  or  Spray. 

The  cold  douche  or  spray  is  of  limited  value.  It  can  be  applied  to  the 
abdomen,  per  vaginam  or  per  rectum. 

II.       MECHANICAL    TREATMENT. 

The  essentials  of  mechanical  treatment  is  forcible  reposition  and  main- 
tenance of  the  viscera,  on  the  visceral  shelves  and  in  the  visceral  fossae — 
i.  e.,  viscera  are  restored  and  maintained  within  the  normal  physiologic 
position. 

The  object  of  mechanical  treatment  is  forcible  visceral  reposition  and 
retention  of  the  organs  (on  their  shelves  in  their  fossae),  i.  e.,  in  their  normal 
physiologic  position  by  means  of  the  abdominal  wall.  In  the  treatment  the 
unfavorable  standing  posture,  the  excessive  physical  labor,  the  imperfect 
respiration  in  the  distal  zone  of  the  chest  and  the  absence  of  tone  in  the 
abdominal  wall  should  be  considered.  The  dislocated  viscera,  in  splanch- 
noptosia,  are  easily  replaced,  reduced  to  their  physiologic  range  of  action 
and  maintained  with  facility  through  rational  therapy  applied  to  the  abdom- 
inal wall.  The  reposition  of  dislocated  groups  of  viscera  in  splanchnoptosia 
to  their  normal  physiologic  range  improves  related  visceral  functions  and 
structure.  Splanchnoptoses  are  mainly  neurotics,  mechanical  reposition  of 
the  visceral  on  their  visceral  shelves  and  in  their  visceral  fossa,  ameliorates 
the  neurosis,  affords  ample  relief  and  comfort.  Splanchnoptotics  are 
neurotics,  consequently  unable  to  judge;  therefore,  should  not  be  informed 
as  to  the  excessive  mobility  of  individual  organs. 

(1).  Abdominal  Supporters. 
Much  utility,  relief  and  comfort  arises  from  the  use  of  properly  fitting 
abdominal  supporters.  The  kinds  we  have  used  are:  (1),  non-elastic,  (2), 
elastic,  and  (3)  the  author's  pneumatic  ax  shafted  rubber  pad  which  can  be 
placed  within  an  elastic  or  non-elastic  abdominal  binder  and  distended  with 
air  to  suit  the  comfort  of  the  patient.  The  objection  urged  against  the  use 
of  an  abdominal  binder  in  splanchnoptosia  that  it  does  not  teach  the  muscles 
self-strength,  is  worthless  as  the  objection  against  the  use  of  a  splint  in 
fractures.  The  fact  to  remember  is  that  the  abdominal  muscles  are  extended, 
stretched  beyond  self  or  independent  help.  Abdominal  supporters  do  not  cure, 
but  properly  fitting  ones  help  the  patient  to  relief,  comfort  and  usefulness. 
It  is  not  sufficient  to  recommend  an  abdominal  binder.  The  physician  should 
examine  it  to  be  sure  that  it  fits  properly,  both  for  the  grade  of  splanchno- 
ptosia and  for  the  avocation  of  the  patient.  The  difficulty  of  fitting  a  proper 
support  is  due  to  the  varying  position  of  the  patient — walking,  sitting  or 
lying.  I  have  invented  a  rubber  air  pad  which  is  the  shape  of  an  axe.  This 
is  placed  within  a  binder  and  subsequently  distended  with  air  through  an 
attached  rubber  tube  to  the  desired  dimension.     The  rubber  pneumatic  pad 


638  THE  ABDOMIXAL   AND   PELVIC  BRAIX 

insures  a  uniform  fitting  of  the  abdomen  like  a  water  bed,  whether  spare  or 
fleshy,  and  also  the  dimensions  may  be  adjusted  tc  the  comfort,  relief  of  the 
patient.  The  binders  are  useful  in  moderate  nephroptosia,  which  is  the 
easiest  of  all  portions  of  splanchnoptosia  to  aid,  but  when  it  has  become 
advanced,  binders  are  not  only  of  little  value  but  frequently  harmful.  In 
severe  or  distinctly  diagnosable  hepatoptosia  (with  liver  projected  into  the 
lesser  pelvis,  I  have  seen  none  or  little  utility  in  binders.  All  tight  waist 
bands  should  be  removed,  and  the  clothing  should  be  suspended  from  the 
shoulders  or  from  hooks  on  a  corset  waist.  If  one  experiments  on  a  dead 
body  with  a  tight-fitting  corset,  the  organ  which  will  suffer  the  most  extensive 
displacement  will  be  the  right  kidney.  All  commercial  tight  corsets  should 
be  abandoned  but  a  so-called  waist  corset  is  useful  to  adjust  and  from  which 
to  suspend  clothing. 

Since  a  binder  is  to  reposit  the  viscera  by  restoring  elongated  and  sepa- 
rated fascial  and  muscular  fibres  of  the  abdominal  walls  it  must  fit  snugly, 
especially  in  distal  abdomen.  Unfortunately  binders  glide  and  slide  and 
do  not  continually  maintain  a  force  on  the  distal  surface  (of  the  visceral 
shelf)  of  the  viscera.  The  viscera  may  glide  distal  to  the  binder.  Two 
rubber  tubes  must  be  employed  passing  between  the  limbs  to  fix  the  binder 
so  that  it  will  not  slip  proximalward.  The  binder  generally  only  forces 
dorsalward  and  proximalward  the  abdominal  wall,  but  the  addition  of  the 
author's  rubber  pad  adds  to  this  the  forcing  of  the  viscera  proximalward  by 
acting  like  a  pregnant  uterus  which  elevates  the  viscera  toward  the  thoracic 
diaphragm.  If  the  splanchnoptosia  is  not  excessively  advanced,  the  rubber 
visceral  air  pad  being  adjusted  and  distended  with  air  while  the  patient  lies 
on  the  back  (Trendelenburg's  posture)  will  prevent  the  viscera  gaining  the 
lesser  pelvis — the  dangerous  ground  for  stenosis  of  ducts,  vessels  and  viscera, 
and  traumatizing  nerve  periphery.  The  binder  should  be  removed  or 
loosened  for  the  night's  rest. 

(2).     Horizontal  Position. 

A  dominant  factor  in  splanchnoptosia  is  venous  congestion  during  erect 
attitude,  hence  the  splanchnoptotic  should  assume  especially  the  horizontal 
position.  When  a  patient  with  established  splanchnoptosia  assumes  the 
erect  attitude,  the  viscera  in  general  pass  distalward  with  the  extra-expanded 
abdominal  walls,  the  veins  immediately  enlarge,  the  abdominal  wall  is  put  on 
a  tension,  and  it  projects  or  bulges  distal  to  the  symphysis  pubis  sufficiently 
to  conceal  the  genitals  from  the  patient's  view.  The  patient  in  the  erect 
attitude  assumes  a  position  of  lordosis  as  in  advanced  pregnancy,  in  order  to 
secure  a  compensator}'  weight  balance. 

In  the  horizontal  position  the  patient  with  splanchnoptosia  should  lie 
on  the  side  and  not  on  the  back.  All  patients  with  established  splanchno- 
ptosia suffer  from  gastro-duodenal  dilatation  (a  phase  in  the  progress  of 
splanchnoptosia)  due  to  pressure  of  the  superior  mesenteric  artery,  vein  and 
nerve  on  the  transverse  segment  of  the  duodenum.  I  experimented  with 
dead  subjects  who  had  been  afflicted  with  splanchnoptosia.   and  when  such 


SPL.l.XClLXOPTOSIA  G39 

subjects  were  placed  on  the  back,  the  viscera,  especially  the  enteronic  loops, 
passed  distinctly  more  and  more  into  the  lesser  pelvis,  dragging  and  tugging 
on  the  superior  mesenteric  artery,  vein  and  nerve,  which  compressed  mon 
and  more  the  transverse  segment  of  the  duodenum.  When  the  subject  of 
splanchnoptosia  lies  on  the  back,  the  enteronic  loops  glide  into  the  lesser 
pelvis,  which  makes  the  superior  mesenteric  artery,  vein  and  nerve  approach 
closer  and  closer  to  the  vertebral  column  and  thus  diminishing  the 
superior  mesenterico-vertebral  angle,  vigorously  compressing  the  transverse 
duodenum. 

I  have  observed  personally  splanchnoptosia  and  gastro-duodenal  dilata- 
tion progress  until  the  stomach  completely  occupied  the  abdomen  like  an 
ovarian  cyst.  (The  more  acute  the  mesenterico-vertebral  angle  becomes,  the 
more  the  transverse  duodenum  segment  is  compressed.)  Pregnancy  increases 
the  (superior)  mesenterico-vertebral  angle,  forcing  proximalward  the  enter- 
onic loops  and  thus  releasing  the  transverse  duodenum  from  pressure.  A 
great  benefit  in  the  wearing  of  an  abdominal  binder  or  Rose's  strapping 
is  to  increase  the  (superior)  mesenterico-vertebral  angle,  releasing  the  duo- 
denum from  compression  and  preventing  increased  gastro-duodenal  dilata- 
tion. Lying  on  the  abdominal  surface  of  the  body,  with  a  pillow  under  the 
thorax  and  the  symphysis  pubis  would  be  the  ideal  position  to  insure  the 
maximum  (superior)  mesenterico-vertebral  angle  (as  it  exists  in  quadrupeds) 
Hence  the  splanchnoptotic  should  lie  in  the  horizontal  lateral  position  as 
much  as  is  convenient  to  increase  the  (superior)  mesenterico-vertebral  angle, 
to  avoid  venous  congestion  and  to  prevent  the  viscera  from  passing  distal- 
ward,  producing  stenosis  and  flexion  of  the  lumen  of  the  vessels,  ducts  and 
viscera.  Lying  on  the  back,  or  standing,  diminishes  the  mesenterico- 
vertebral  angle  and  increases  the  compression  of  the  duodenum  by  the 
mesenteric  vessels  and  nerves. 

(j).     Massage. 

The  massage  of  the  abdominal  wall  as  well  as  that  of  the  tractus  intes- 
tinalis  aids  materially  in  the  treatment.     However,  it  is  of  limited  value. 

(4).     Achilles  Rose's  Adhesive  Strapping. 

I  wish  to  recommend  strongly  the  strapping  of  the  splanchnoptotic 
abdomen  by  rubber  adhesive  plaster  introduced  first  by  Dr.  Achilles  Rose  of 
New  York  and  independently  later  by  Dr.  N.  Rosewater  of  Cleveland,  Ohio, 
Dr.  Walther  Nicholas  Clemm  of  Darmstadt,  Germany,  and  Dr.  B.  Schmitz 
of  Wildungen,  Germany. 

Dr.  Achilles  Rose's  strapping  method  is  rational,  economical  and  practi- 
cal and  affords  prompt  comfort  and  effective  relief.  Abdominal  binders  slip 
and  glide  but  adhesive  straps  will  remain  permanently  in  place  and  not  slip. 

Method  of  Applying  the  Adhesive  Strap. 

Previous  to  applying  the  abdominal  adhesive  straps  the  abdominal  skin 
should  be  thoroughly  cleaned  with  soap  and  water  and  later  alcohol  to  dissolve 
oily  substances  applied  in  the  line  of  adhesive  straps.     The  patient  should 


640  THE  ABDOMIXAL  AXD  PELVIC  BRAIX 

be  strapped  either  in  the  standing  position  by  elevating  the  abdominal  wall 
(Glenard's  belt  test)  by  the  hands  before  the  straps  are  applied  or  strapped 
in  the  Trendelenburg's  position. 

Place  an  adhesive  strap  2  inches  in  width  around  the  trunk  immediately 
proximal  and  parallel  to  the  crest  of  the  pubis,  Poupart's  ligament  and  crests 
of  the  ilia,  superimposing  or  overlapping  the  adhesive  straps  on  the  medial 
dorsal  line.  The  dorsal  position  of  the  adhesive  straps  is  located  considera- 
ble proximal  to  the  ventral  position  which  endows  the  straps  with  its  useful, 
visceral  supporting  properties. 

Secondly,  apply  a  pyramid  formed  adhesive  strap  3  inches  wide  ventrally 
and  2  inches  wide  dorsally  immediately  proximal  and  parallel  to  the  first 
adhesive  strap.  These  two  lateral  adhesive  straps  overlap  ventrally  and 
dorsally.  This  method  of  adhesive  strapping  forces  the  abdominal  wall 
and  viscera  proximalward  so  that  the  relaxed  portion  of  the  abdominal 
wall  is  in  the  region  of  the  umbilicus  and  stomach.  In  other  words  the 
adhesive  strapping  reverses  the  position  of  the  abdominal  splanchnoptosia 
(atonia  gastrica),  i.  e.,  the  excessive  mobile  viscera  and  relaxed  abdominal 
wall  are  transferred  to  the  proximal  end  of  the  abdomen  (instead  of  the  distal 
end).  I  allow  the  adhesive  straps  to  remain  in  position  for  10  days  to  a 
month.  Local  bathing  can  be  practiced  with  the  adhesive  straps  in  position 
(avoiding  the  moistening  of  the  immediate  region  of  the  straps).  Beginners 
are  apt  to  apply  the  strap  too  tightly.  Dr.  E.  Gallant  of  New  York  reports 
excellent  results  from  his  corset  method  of  treatment.  Patients  experience 
prompt  and  ample  relief  from  mechanic  supports,  avoiding  the  danger  of  a 
fragmentary  operation,  its  recurrence  and  the  inevitable  unfavorable  cellular 
and  peritoneal  adhesions  accompanying  viscero-pexy. 

(III).      SURGICAL. 

Surgery  is  not  advised  excepting  for  obvious  pathologic  lesions. 
Splanchnoptosia  cannot  be  cured  by  surgery  though  every  abdominal  viscus 
has  imposed  on  it  a  '"Pexy. "  Some  surgeons  encourage  splanchnoptosia  by 
allowing  and  advising  the  patient  to  leave  the  bed  in  an  incredible  limited 
time  subsequent  to  an  abdominal  section  or  peritonotomy.  The  treatment 
of  splanchnoptosia  is,  in  general,  not  by  the  scalpel,  needle  and  suture.  The 
surgical  therapeutics  employed  to  relieve  in  splanchnoptosia  are:  (a)  appli- 
cation to  the  abdominal  wall,  (b)  viscero-pexy,  (c)  visceral  anastomosis. 

(A)     Abdominal  Walls. 

(1)  Resection  of  portions  of  abdominal  wall.  (2)  Union  of  musculi  recti 
abdominalis  in  a  simple  sheath.     (3)  Superposition  of  abdominal  wall. 

(/).  Resection  of  Portions  of  the  Abdominal  Wall.  The  early  attempts 
to  diminish  the  abdominal  cavity  in  splanchnoptosia  originated  from  the 
gynecologists,  particularly  from  Prof.  Karl  Schroeder  and  Dr.  Landau  of 
Berlin,  Germany.  I  was  a  pupil  of  Dr.  Theodore  Landau  in  1555  and  his 
books,  "Wander  Niere"  and  "Wander  Leber,"  have  been  for  teachers  and 
authors  an  unbounded  source  of  credited  and  uncredited  data. 


SPLANCHNOPTOSIA 


641 


(  •■.     Union  of  the  Musculi  Recti  Ab  dominates  in  a  Single  Sheath.     My 

attention  was  first  called  to  the  subject  of  relaxed  abdominal  walls  by  Prof. 
Karl  Schroeder  whose  pupil  I  was  for  a  year.  In  that  year  (1884-1885)  Prof. 
Schroeder  of  Berlin,  Germany,  the  greatest  gynecologic  teacher  of  his  age, 
was  at  his  zenith  of  fame,  and  his  clinic  was  vast.  In  fact,  he  tapped  the 
whole  of  Europe  for  his  material.  He  discussed  in  his  clear  style  the  mis- 
fortune of  lax  abdominal  wall  lying  between  the  diastatic  recti  abdominales. 


ABDOMINAL  WALLS 

Fig.  206.     Presenting  the  fascia  and  muscles  of  the  abdominal  wall  with  the 
introduction  of  sutures. 


He  then  united  the  sheaths  of  the  recti  in  the  median  line.  But  Prof. 
Schroeder  said  then  to  his  pupils  that  he  was  not  fully  satisfied,  however,  it 
was  the  best  surgery  that  he  knew  at  that  time.  Later  German  surgeons 
improved  Schroeder's  ideas  by  splitting  the  sheaths  of  the  two  recti  muscles 
and  enclosing  both  muscles  in  one  sheath  by  uniting  the  recti  muscle  sheaths 
dorsally  and  ventrally  and  dorsally  to  the  recti  muscles. 

In  1895,  Dr.  Orville  W.  MacKellar  and  I  operated  on  a  woman  pregnant 


642  THE   ABDOMINAL   AND   PELVIC  BRAIN 

four  or  five  months,  where  the  diastasis,  the  musculi  recti  abdominales  was 
very  marked,  and  the  uterus,  on  coughing  or  extra  intra-abdominal  pres- 
sure, would  project  between  the  recti  abdominales.  We  united  the  split 
sheaths  of  the  recti  muscles  ventral  and  dorsal,  enclosing  the  two  musculi 
recti  abdominales  in  one  sheath.  Dr.  MacKellar  reports  to  me  at  present 
(1906)  that  his  patient  is  perfectly  well,  and  the  operation  was  a  success.  Dr. 
MacKellar  was  at  the  deliver}'  and  the  recti  sheaths  remained  perfectly  intact. 
For  the  post-operative  hernia,  for  years  past  at  the  Mary  Thompson  Hospital, 
I  have  split  the  recti  and  enclosed  them  in  a  single  sheath.  Every  one  with  suffi- 
cient experience  knows  that  post-operative  hernia  of  any  considerable  size, 
in  women  over  40,  is  in  every  case  accompanied  by  splanchnoptosia.  Dr. 
MacKellar  and  I  have  records  to  show  that  11  years  after  enclosing  the  two 
recti  abdominales  in  a  single  sheath,  for  splanchnoptosia,  the  operation  is  a 
success.  The  mesenteries  are  not  for  mechanical  support  to  suspend  the 
viscera,  but  to  act  as  a  neuro-vascular  visceral  pedicle,  and  to  prevent  the 
entanglement  with  other  viscera.  It  is  the  abdominal  wall  that  maintains 
the  viscera  in  position. 

Besides,  I  showed  in  over  600  detailed  records  of  personal  autopsic 
abdominal  inspection,  that  in  96%  of  subjects  the  enteron  had  a  mesenteron 
sufficient  in  length  to  herniate  through  the  inguinal,  femoral  and  umbilical 
rings.  Hence  the  mesenteries  must  be  viewed  as  neuro-vascular  visceral 
pedicles,  and  not  as  suspensory  organs,  while  the  abdominal  walls  are  the 
essential  supporters  and  retainers  of  the  viscera.  And  as  every  anatomist 
knows,  the  recti  abdominales  are  among  the  chief  regulators  or  governors  of 
visceral  poise,  at  least  they  retain  the  viscera  in  their  first  delicate  normal 
balance. 

In  uniting  the  two  recti  abdominales  into  a  single  sheath  the  operation 
may  be  performed  without  entering  the  peritoneal  cavity  or  after  laparotomy. 
During  the  past  4  years  I  have  practically  abandoned  the  union  of  the  muscli 
recti  abdominales  in  a  single  sheath  for  the  operation  of  superposition,  over- 
lapping of  the  abdominal  walls,  taught  me  by  Mr.  Jordan  Lloyd,  of  Birming- 
ham, England,  in  1891. 

(3).  Superposition  of  the  Abdominal  Walls.  In  1891  in  a  visit  to  Mr. 
Jordan  Lloyd  of  Birmingham,  England,  he  demonstrated  to  me  the  operation 
of  superposition  (overlapping)  of  the  abdominal  walls  in  abdominal  section 
to  strengthen  the  line  of  union.  He  used  a  matras  form  of  suture.  Since 
that  time  I  have  employed  the  superposition  (overlapping,  like  a  double- 
breasted  coat)  of  the  abdominal  wall.  Contrary  to  Mr.  Jordan  Lloyd,  I 
employ  the  buried  silver  wire  suture — some  3  to  an  inch.  The  superposition 
or  overlapping  of  the  abdominal  walls  in  splanchnoptosia  is  the  most 
rational,  effective,  durable  and  successful  of  all  parietal  surgical  procedures. 
It  diminishes,  to  the  desired  extent,  the  abdominal  cavity,  forcibly  repositing 
organs  on  their  visceral  shelves  and  in  their  visceral  fossae  and  retaining 
them  in  their  normal  physiologic  position.  I  have  superposed,  or  overlapped, 
some  abdominal  walls  as  much  as  3  inches  on  each  side,  diminishing  the 
abdominal  cavity  by  six  inches  of  the  ventral  wall.     I  observed  that  some 


SPLANCHNOPTOSIA  643 

patients  with  extensive  superposition  of  the  abdominal  wall,  and  consequent 
diminution  of  the  abdominal  cavity,  complained  for  a  few  months  of  com- 
pression feelings,  as  if  the  abdomen  were  too  tight  or  constricted. 

(B)      Viscero-pexy  {fixation  of  organs). 

All  abdominal  viscera  are  physiologically  mobile,  hence,  to  perform 
viscero-pexy,  or  visceral  immobilization,  fixation  of  any  organ,  is  unphysio- 
logical  or  in  other  words  viscero-pexy  produces  a  physiologic  and  anatomic 
lesion.  Excessive  visceral  mobility  is  exchanged  for  visceral  fixation.  That 
is,  to  cure  one  disease  (excessive  visceral  mobility),  another  lesion  (visceral 
fixation)  is  substituted.  Therefore  viscero-pexy  is  in  general  an  irrational, 
harmful,  surgical  procedure.  However,  in  surgery  as  in  other  matters 
the  lesser  evil  should  be  chosen,  i.  e.,  one  should  choose  which  is  the 
greater  evil,  excessive  visceral  mobility  or  visceral  fixation — viscero- 
pexy.  The  lesion  of  viscero-pexy  or  visceral  fixation  is  compromisa- 
tion  of  physiology  and  anatomy,  viz. :  the  lymph  and  blood  circulation  as 
well  as  peristalsis,  absorption,  secretion,  sensation,  are  compromised.  Nerve 
periphery  is  traumatized.  The  viscero-pexy  in  order  of  frequency  have  been 
the  following:  hystero-pexy,  nephro-pexy,  gastro-pexy,  hepato-pexy,  spleno- 
pexy and  colo-pexy.  In  general  viscero-pexy  is  irrational  surgery  and  will 
be  limited  in  application,  as: 

(a)  It  attempts  to  cure  one  lesion  (excessive  visceral  mobility)  by  pro- 
ducing another  lesion  (visceral  fixation).  Which  is  the  worse?  It  is  unjusti- 
fiable surgery  that  substitutes  one  pathologic  visceral  position  for  another 
(for  a  mobile,  pathologic  visceral  position  is  no  doubt  less  damaging  than 
a  fixed  pathologic  position). 

(b)  It  attempts  to  cure  a  general  defect  or  disease  (splanchnoptosia — 
excessive  visceral  mobility)  by  fixation  (a  physiologic  and  anatomic  lesionj 
of  a  single  part  (e.  g.,  nephroptosia)  fragment  of  the  dislocated  viscera. 
Also,  when,  accidentally,  by  trauma  ptosis  of  single  viscera  occur  the  dis- 
tinct, marked  symptoms  and  suffering  are  not  indicated.  Instead  of  irrational, 
individual  viscero-pexy,  the  diminution  of  the  abdominal  cavity  is  more 
rationally  secured  by  Rose's  abdominal  strapping  (or  a  binder)  or  by  the 
superposition,  overlapping  of  the  abdominal  walls  (mechanical),  as  this  does 
not  produce  the  unfortunate  peritoneal  fixation  lesions  of  viscero-pexy  yet 
forcibly  reposits  the  viscera  on  their  normal  anatomic  shelves  and 
within  physiologic  range.  If  splanchnoptosia  is  to  be  cured  by 
viscero-pexy  it  will  require  multiple  visceral  and  parietal  operations 
on  one  and  the  same  patient  as  nephro-pexy,  gastro-pexy,  spleno- 
pexy, hepato-pexy,  entero-pexy  and  in  females  (the  usual  subjects) 
utero-pexy.  Observe  what  extreme  compromisation  of  visceral  anatomy 
and  physiology  this  would  entail.  Besides,  the  thoracic  and  abdom- 
inal walls  will  require  effective  repair  (diminution).  Hence  a  dangerous 
number  of  surgical  repetitions  would  confront  the  patient. 

(c)  The  viscero-pexy  (a  lesion  of  visceral  fixation)  is  generally  tempo- 
rary as  the  viscus  becomes  practically    eleased  sooner  or  later  from  absorp- 


644  THE  ABDOMLXAL  AXD  PELVIC  BRALX 

tion  of  the  adjacent  artificial  parietovisceral  exudate,  from  absorption  or  the 
yielding  of  suture,  from  the  trauma  of  the  visceral  peristalsis,  from  adjacent 
muscular  trauma,  from  the  trauma  of  respiration  (especially  the  diaphragm), 
from  lack  of  support  of  the  abdominal  wall. 

d  i  The  viscero-pexy  compromises  visceral  function  and  structure,  of 
which  the  most  striking  example  is  that  of  dystocia  due  to  hystero-pexy  I 
have  performed  autopsy,  the  death  being  directly  due  to  dystocia  resulting 
from  hystero-pexy.  Fixation  damages  other  viscera  similarly,  perhaps 
according  to  the  degree  of  solidarity  of  fixation. 

(e)  The  peritonotomy  or  the  invasion  of  the  peritoneum  alone,  regard- 
less of  the  viscero-pexy,  may  produce  considerable  damaging  peritoneal 
adhesions,  compromising  not  only  the  structure  and  function  of  the  fixed 
viscus,  but  also  of  adjacent  viscera.  Peritoneal  adhesions  are  ample  reasons 
in  many  subjects  for  primary  or  secondary  peritonotomy.  I  have  shown  in 
hundreds  of  autopsies  that  peritoneal  adhesions  damage  viscera  by  compro- 
mising anatomy  and  physiology,  e.  g.,  especially  in  the  caeco-appendicular, 
gall-bladder,  sigmoid  and  pelvic  regions — that  a  peritonotomy  is  required. 

(f)  The  patient  is  not  suffering  nor  are  the  symptoms  due  to  dislocation 
of  single  organs  (in  splanchnoptosia) — the  suffering  and  symptoms  are  the 
result  of  general  dislocation  of  viscera  (splanchnoptosia — neurosis)  and 
extra-expansion  of  the  abdominal  and  thoracic  walls,  i.  e.,  splanchnoptosia. 

(g)  Viscero-pexy  is  irrational  because  it  compromises  visceral  function 
(peristalsis,  absorption,  secretion  sensation)  and  structure  (the  connective 
tissue  and  the  parenchyma  of  the  organs  is  damaged). 

(h)  Viscero-pexy  compromises  circulation  (blood  and  lymph).  It 
traumatizes  nerve  periphery.  It  deranges  nourishment,  resulting  in  malassi- 
milation,  neurosis. 

(i)  Viscero-pexy  is  a  pathologic  surgical  substitute  for  hygienic  meas- 
ures with  a  high  cost  and  risk.  The  anatomic  rest  (maximum  quietude  of 
voluntary  muscles)  and  physiologic  rest  (minimum  function  of  viscera)  in 
bed,  with  mental  hope  of  cure,  tells  the  favorable  story  rather  than  the 
viscero-pexy. 

(j)  The  patient  recovers  after  the  viscero-pexy  from  symptoms  which 
did  not  practically  belong  to  the  organ  attacked.  It  was  a  mistake  in 
diagnosis  and  an  unnecessary  operation.  E.  g.,  to  fix  a  retroverted  state  of 
the  uterus  is  to  substitute  one  pathologic  condition  for  another,  and  also 
the  subject  is  not  suffering  from  the  retroversion  but  either  from  complica- 
tions or  disease,  as  neurosis. 

(k)  Three  views  may  be  held  on  the  favorable  reports  in  viscero-pexy 
or  visceral  fixation,  viz. :  (1)  the  patient  secures  a  period  of  favorite 
anatomic  and  physiologic  rest  in  bed  after  the  viscero-pexy — with  mental 
hope  of  cure.  In  other  words  the  viscero-pexy  is  a  hygienic  measure — 
with  high  price  and  risk.  (2)  The  patient  recovers  after  the  viscero-pexy 
from  symptoms  which  did  not  belong  to  the  attacked  organ.  The  symptoms 
presented  by  the  patient  were  due  to  other  causes — especially  neurosis 
(neurasthenia,  hysteria).     It  was  a  mistaken  diagnosis.     Hence  for  individual 


SPLANCHNOPTOSIA  645 

viscero-pexy  should  be  substituted  rational  hygienic  measures  and  correct 
diagnosis.  Neurosis  should  not  be  mistaken  for  splanchnoptosia  or  entero- 
ptosia.  (3)  A  third  view  in  the  favorable  reports  of  viscero-pexy  is  that 
they  are  prematurely  published.  The  operation  from  the  anatomic  and 
physiologic  rest  in  bed,  as  well  as  diminution  of  the  accompanying  neurosis, 
has  afforded  temporary  relief.  Individual  viscero-pexy  in  the  majority  of 
subjects  does  not  secure  permanent  relief. 

INDIVIDUAL  VISCERO-PEXY. 

Viscero-pexy  on  two  organs — kidney  and    uterus — has  become   unfortu 
nately  prevalent  during  the  past  decade. 

NEPHROPEXY. 

Nephro-pexy  sJiould  be  performed  for  periodic  hydro-ureter  only. 

If  in  nephroptosia  one  detects  distinct  renal  pain,  renal  tenderness,  renal 
hypertrophy  and  that  the  ureteral  pelvis  of  the  same  side  contains  a  greater 
quantity  of  urine  than  the  pelvis  of  other  side,  periodic  hydro-ureter  has 
probably  begun.  If  in  a  kidney  of  extensive  mobility,  and  irregular  pain 
presents  it  is  probably  due  to  rotation  of  the  kidney  on  its  uretero-neuro- 
vascular-vascular-visceral  pedicle  (Dietl's crisis)  and  ureteral  dilatation  (peri 
odic  hydro-ureter)  has  probably  begun. 

As  regards  nephro-pexy  there  is  practically  one  condition  which  indi- 
cates nephro-pexy  and  that  is  periodic  hydro-ureter.  In  this  case  the 
damage  of  periodic  hydro-ureter  is  greater  than — unphysiologic  renal  fixation 
— that  of  nephro-pexy.  Besides,  nephro-pexy  is  generally  not  permanent;  the 
kidney  again  appears  in  the  field  of  nephroptosia.  The  patient  has  assumed 
the  risk  of  operation,  with  its  consequent  anatomic  and  physiologic  damage, 
peritoneal  and  connective  tissue  adhesions,  for  temporary  relief.  The  multi- 
ple methods  of  executing  nephro-pexy  condemn  it.  Practically  every  advo- 
cate of  the  irrational  nephro-pexy  pretends  to  possess  his  own  method.  Also 
nephroptosia  is  but  a  fragment  of  splanchnoptosia,  and  to  produce  a  single, 
pathologic,  unphysiologic,  harmful  viscero-pexy  to  cure  a  general  spanchnopto- 
sia  adds  further  damage  to  the  patient.  Nephro-pexy  has  perhaps  a  mortality 
of  2f/o  (the  dead  are  not  reported — the  living  are  reported).  In  nephroptosia 
the  most  rational  treatment  is  mechanical  reposition  and  retention  of  the  kid- 
ney by  means  of  mechanical  supports  (for  60%  of  adult  women  possess  mo- 
bile kidney),  it  avoids  operation  with  consequent  connective  tissue  and  peri- 
toneal adhesions.  It  is  a  doubtful  justifiable  surgical  procedure  to  per- 
form nephro-pexy  on  a  replacable  kidney,  when  the  organ  can  be  retained  by 
mechanical  means,  i.  e.,  by  utilizing  the  abdominal  wall  through  a  binder — 
strapping — if  no  periodic  hydro-ureter  exists  (because  mechanical  aids 
will  reposit  and  maintain  the  kidney  in  its  normal  position  a  1000  times  more 
physiologic  than  fixation — nephro-pexy).  If  nephro-pexy  be  performed  (for 
periodic  hydro-ureter)  it  should  be  executed  according  to  the  Senn  method — 
i.  e.,  the  distal  pole  of  the  kidney  should  be  placed  in  the  wound  in  the 
abdominal  wall  and  maintained  there  by  a  loop  of  gauze  without  sutures. 


646  THE  ABDOMINAL  AND   PELVIC  BRAIN 

Later  the  kidney  is  fixed  in  this  position  by  granulations  and  the  skin  is  drawn 
over  its  longitudinal  border  by  means  of  adhesive  straps. 

Hystero-pexy. 

As  regards  fixation  of  the  genital  organs  we  offer  the  following  considera- 
tion: Hystero-pexy  should  not  be  performed  on  a  reproductive  subject.  (Alex- 
ander operation  is  a  pathologic  surgical  substitute  for  hygienic  measures  at  a 
high  cost  and  risk.  It  demands  repetition  as  frequent  as  man  requires  his 
hair  cut.)  Since  the  primary  support  of  the  genitals  is  the  pelvic  floor, 
rational  surgery  suggests  pelvic  floor  repair  for  general  support  in  visceral 
ptosis.  Anatomically  and  physiologically  the  genitals  belong  permanently 
in  the  pelvis.  The  genital  organs  are  permanent  pelvic  organs,  hence  it  is 
irrational  to  remove  them  from  the  pelvis  into  the  abdomen  in  order  to  fix 
them  permanently  to  the  abdominal  wall — the  genital  nerve,  lymph  and 
blood  apparatus  are  located  in  the  pelvis  in  the  resting  state. 

To  create  new  external  supports  external  to  the  pelvis  for  the  genitals 
(ventral  hystero-pexy)  is  unphysiologic,  pathologic,  as  it  dislocates  the  organs 
and  compromises  structure  and  function — especially  mobility  and  peristalsis — 
beside  disturbing  adjacent  organs.  The  utility  of  ventral  (abdominal)  hystero- 
pexy has  not  been  established;  however,  its  damaging  effects  have  been 
recognized  many  hundreds  of  times :  (a)  in  pain  following  the  operation,  (b) 
from  dystocia,  (c)  in  abortions,  due  to  it,  (d)  in  the  necessity  of  surgical 
procedures  in  parturitions  (as  instrumental  delivery  symphysiotomy, 
Caesarian  section,  Porro  operation),  (e)  in  the  necessity  of  producing  abor- 
tions, (f)  from  postoperative  hernia  (Theilhaber  repor' 3  30%  of  hernia 
subsequent  to  ventral  hystero-pexy — and  these  were  p  ^ctically  originally 
aseptic  subjects),  (g)  in  the  mortality  of  some,  2%. 

To  forcibly  substitute  or  transform  secondary  genital  supports  into 
primary  ones  or  to  create  artificial  ones  is  rarely  applicable  and  of  doubtful 
utility.  However,  secondary  supports  are  more  rational  than  to  create 
artificial  new  supports  external  to  the  pelvis.  The  Alexander  operation,  of 
shortening  the  round  ligaments,  is  imposing  on  a  secondary  uterine  support 
(the  round  ligaments)  the  duty  of  a  primary  uterine  support. 

(B)      Visceral  Anastomosis. 

The  anastomosis  of  viscera  employed  to  relieve  in  splanchnoptosia  are 
the  stomach  and  enteron.  The  reason  for  this  is  that  gastro-duodenal  dilata- 
tion is  simply  a  phase  in  splanchnoptosia  due  to  the  compression  of  the 
duodenum  by  the  superior  mesenteric  vessels.  Gastro-enterostomy  allows 
the  food  to  escape  from  the  stomach  into  the  enteron  without  first  passing 
through  the  obstructed  portion  of  th^  duodenum  from  the  compression  of  the 
superior  mesenteric  artery  vein  and  nerve.  With  rapid  stomach  evacuation 
and  no  food  in  the  duodenum  the  gastro-duodenal  dilatation  is  quickly 
changed  to  gastro-duodenal  contraction.  (See  discussion  of  gastro-duodenal 
dilatation.) 


SPLANCHNOPTOSI.  1  647 

RESUME  AS  REGARDS  SPLANCHNOPTOSIA. 

1.  Splanchnoptosia  presents  two  grand  divisions,  viz. :  I.  Thoracic 
splanclinoptosia\\\i\c\\\x\c\xi<\v$,  the  factors  of:  (a)  relaxation  of  the  thoracic 
wall  (with  diaphragm),  (b)  thoracic  splanchnoptosia  (heart  and  lungs),  (c) 
consequent  deranged  function  of  the  thoracic  viscera  and  wall  (respiration 
and  circulation).  II.  Abdominal  splanchnoptosia  which,  includes  the  factors 
of:  (d)  relaxed  abdominal  walls  (atonia  gastrica),  (e)  splanchnoptosia  of 
abdominal  viscera  (the  six  visceral  tracks),  (f)  elongation  of  mesenteries 
(neuro-vascular  visceral  pedicle),  (g)  gastro-duodenal  dilatation  (due  to  com- 
pression of  transverse  portion  of  the  duodenum  by  the  superior  mesenteric 
artery  vein  and  nerve),  (h)  altered  form  of  the  abdomen  (erect — pendulous, 
prone — projecting  laterally). 

In  general,  in  splanchnoptosia,  canalization  is  compromised,  nerve  pe- 
riphery traumatized,  common  visceral  function  (peristalsis,  secretion,  absorp- 
tion, sensation)  deranged;  circulation  (blood,  and  lymph)  disordered; 
respiration  disturbed — ending  in  malnutrition  and  neurosis. 

Splanchnoptosia  compromises  the  lumen  of  ducts,  vessels  and  viscera — 
tubular  canals — through  flexion,  stenosis,  decalibration,  elongation,  constric- 
tion. 

2.  The  numerous  and  complex  groups  of  symptoms  produced  by 
splanchnoptosia  must  be  considered  independent  of  inflammatory  processes. 

The  symptoms  of  the  splanchnoptotic  are  complex  and  numerous. 
Each  cause  in  splanchnoptosia  produces  a  vicious  circle  of — pathologic 
physiology — pathologic  effects  on  the  visceral  tracts — digestive,  genital,  urin- 
ary, lymphatic,  vascular,  nervous,  respiratory — impairing  nourishment. 
Splanchnoptosia  is  often  mistaken  and  wrongly  diagnosed  as  neurasthenia, 
nervous  exhaustion,  hysteria,  spinal  anaemia,  menopause,  nervous  dyspepsia, 
and  neurosis. 

Splanchnoptosia  appears  to  be  chiefly  of  congenital  disposition  as  its  sub- 
jects are  generally  feeble,  slender,  atonic,  neurotic,  marked  with  a  habitus, 
ill-nourished,  deficient  in  vital  force  with  marked  inferior  physiologic  func- 
tion and  inferior  anatomic  structure,  with  apparently  a  hard  struggle  to  battle 
for  life  and  against  its  forces.  It  seems  sufficiently  difficult  for  the 
splanchnoptotic  to  live  merely — without  attempting  productive  labors  or  to 
rear  children.  Splanchnoptotics  are  inferior  physically  and  incapable  of 
sustained  effort  mentally.  They  are  easily  fatigued  and  present  a  neurotic 
life.  Splanchnoptosia  rests  on  evident  inferior  anatomy  and  inferior  physi- 
ology— on  stigma,  on  habitus,  on  heredity.  The  heredity  of  the  splanchnop- 
totic is  habitus  splanchnopticus. 

In  splanchnoptosia  the  visceral  tracts  are  deranged  in  function  (mani- 
festing pathologic  physiology)  and  their  anatomy  is  distorted  (the  elastic, 
muscular  and  connective  tissue  fibres  are  elongated  and  separated). 
Splanchnoptotic  organs  are  liable  to  become  hypertrophic — e.g.,  spleen, 
liver,   uterus — from  hyperaemia  (especially  venous  congestion). 

3.  In  splanchnoptosia  in  common,  the  tractus  intestinalis,  urinarius, 
vascularis,     respiratorius,     lymphaticus,      genitalis,     experience      excessive, 


G48  THE  ABDOMINAL  AND  PELVIC  BRAIN 

deficient  disproportionate  function  peristalsis,  absorption,  secretion,  sensa- 
tion) ;  excessive  mobility  (distalward  dislocation),  obstruction  (from  flexion), 
pain. 

In  splanchnoptosia  the  chief  manifestation  of  distinctive  characteristic 
features  are: 

(a)  From  the  tractus  intestinalis,  viz.  :  indigestion,  fermentation,  meteor- 
ism,  constipation,  malassimilation. 

(b)  From  the  tractus  urinarius,  hydro-ureter  (periodic),  axial  rotation 
of  renal  pedicle  (Dietl's  crisis). 

(c)  From  the  tractus  genitalis,  hyperaemia,  hypertrophy,  abortion. 

(d)  From  the  tractus  vascularis,  hyperaemia,  anaemia,  cardiac  and 
aortic  palpitation. 

(e)  From  the  tractus  lymphaticus,  congestion,  decongestion,  hyper- 
trophy. 

(f)  From  the  tractus  nervosus,  irritability  (from  trauma),  instability, 
debility,  neurosis. 

(g)  From  the  tractus  respiratorius,  excessive,  deficient,  disproportionate 
respiration. 

The  splanchnoptotic  is  the  typical  subject  of  manifest  pathology 
physiology  (i.  e.,  he  lives  in  the  zone  between  normal  physiology  and 
pathologic  anatomy). 

Splanchnoptosia  consists  of  a  distalward  dislocation  of  thoracic  and 
abdominal  viscera  resulting  from  extra  extended  walls.  A  viscus  is  dislocated 
when  it  is  permanently  fixed.  More  adults  have  dislocated  viscera  (e.  g., 
splanchnoptosia  and  from  peritoneal  adhesions)  than  normal  ones. 

B.  Stillar's  costal  stigma  or  floating  tenth  rib — costa  decima  fluctuens — 
I  have  studied  insufficiently  to  make  authoritative  statements. 

The  objective  appearance  of  the  splanchnoptotic  is  neurotic,  slender 
with  gracile  skeleton,  flattened  thorax,  increased  intercostal  spaces,  delicate 
and  poorly  nourished,  pale,  non-energetic;  a  sad,  helpless  picture.  Splanch- 
noptoses form  a  distinct  class  with  peculiar  characteristics  resembling  the 
class  of  tubercular  subjects  to  which  they  are  related. 

Splanchnoptosia  is  a  general  disease  of  the  abdominal  and  thoracic 
viscera;  the  tractus  respiratorius,  intestinalis,  vascularis,  nervosus,  urinarius, 
lymphaticus,  genitalis  are  equally  affected,  but  from  anatomic  mechanism 
and  manifestations  the  tractus  nervosus  (neurosis)  and  tractus  intestinalis 
(indigestion),  appear  to  suffer  the  most. 

Since  my  clinic  and  private  practice  has  consisted  of  85%  of  women  I 
can  not  estimate  the  percentage  of  splanchnoptosia  as  regards  sex;  however, 
in  over  650  personal  autopsic  abdominal  inspections  (475  men,  160  women) 
splanchnoptosia  was  amply  evident  in  men. 

Rapidly  repeated  gestations  play  an  influential  role  in  progressive 
splanchnoptosia,  as  when  the  fascial,  elastic  and  muscular  fibre  of  some 
abdominal  walls  are  once  well  elongated  and  separated  (expanded)  they  cfo 
not  return  to  normal. 


SPLANCHNOPTOSIA 

The  second,  third,  fourth,  fifth  decades  of  life  are  the  chief  ages  of 
suffering  in  splanchnoptosia. 

The  symptoms  which  chiefly  predominate  in  splanchnoptosia  are  from 
the  side  of  the  nervous,  digestive,  and  circulatory  systems.  From  the 
nervous  sphere  one  observes  mental  depression,  melancholy,  excitability, 
irritability,  and  the  nervous  stigmata,  as  e.  g.,  neurosis,  hysteria,  neuras- 
thenia. From  the  side  of  the  circulatory  system  one  observes  hyperaemia, 
anaemia,  cardiac,  and  aortic  palpitations— excessive  peristalsis.  The  aorta 
may  appear  as  a  beating  tumor  which  may  be  mistaken  for  aortic  aneurysm, 
because  the  aorta  (while  in  the  prone  attitude)  is  so  extensively  uncovered, 
exposed  by  separated  viscera,  presenting  a  protection  of  thin  abdominal  wall 
only. 

From  the  side  of  the  digestive  system  one  observes  indigestion,  fer- 
mentation, meteorism,  constipation.  These  three  groups  of  symptoms  are 
marked  in  every  advanced  case  of  splanchnoptosia. 

I  can  not  agree  with  Meinert  in  attempting  to  establish  an  evident 
etiologic  relation  between  chlorosis  and  splanchnoptosia.  I  could  observe 
no  distinct    relation  in  series  of  observation. 

The  large  number  of  women  who  have  not  borne  children,  who  have  not 
laced  tight,  who  have  not  suffered  from  ascites,  nor  wasting  disease,  how- 
ever being  afflicted  with  splanchnoptosia,  indicates  a  predisposing  or  con- 
genital factor. 

In  splanchnoptosia  there  are  two  factors  to  study,  viz. :  (a)  congenital 
and  predisposing  cause,  (b)  exciting  cause.  The  secondary  or  exciting 
causes  are  any  forces  which  tend  to  debilitate  (elongate  and  separate  the 
fibres  of  the  abdominal  parietes),  the  abdominal  wall,  as  rapidly  repeated 
gestation,  abdominal  tumors,  ascites,  septic  disease,  constipation,  and  wast- 
ing disease,  especially  the  disappearance  of  panniculus  adiposus  and  adjacent 
to  the  viscera.  A  congenitally  defective  system  may  persist  in  maintaining 
fair  health ;  however,  exciting  or  aggravating  causes  may  precipitate  invalid- 
ism with  facility. 

Splanchnoptosia  may  exist  with  no  recognizable  symptoms,  however, 
while  the  subject  is  in  fair  physical  condition.  The  rule  is  that  splanch- 
noptosia may  be  accompanied  by  pathologic  physiology  (and  pathologic 
anatomy)  in  part  or  all  of  the  visceral  tracts  (thoracic  or  abdominal). 

Splanchnoptosia  is  a  general  disease — not  a  local  one.  It  belongs  to  the 
area  of  respiration,  which  is  the  trunk.  This  is  well  to  remember  when  the 
pexyite  is  attempting  to  impose  fixation  on  some  single  viscus  (which 
should  remain  physiologically  mobile). 

The  physician  should  learn  to  discriminate  the  effects  in  splanchnoptosia 
from  the  different  visceral  tracts,  e.  g.,  nephroptosia  and  genital  ptosis 
manifest  almost  identical  symptoms.  The  immediate  relief  by  mechanical 
treatment  of  forcible  reposition  by  adhesive  strapping  would  decide  in  favor 
of  nephroptosia  as  support  from  the  abdominal  walls  is  inefficient  in  genital 
ptosis. 

Observe  how  nephroptosia  from  trauma  of  the  plexus  renalis  produces 


650  THE   ABDOMIXAL   AXD   PELVIC   BRAIN 

reflex  symptoms  on  the  proximal  end  of  the  tractus  intestinalis,  ending  in 
nausea,  pain,  malassimilation,  constipation,  neurosis.  Ureteral  calculus 
induces  vomiting,  and  sooner  or  later  renal  and  gastric  disease  coexists. 
Genital  disease  occasions  more  gastric  disturbances  than  the  reverse  because 
the  gastric  functions  (secretion,  absorption,  peristalsis,  sensation)  are 
deranged  more  effectually  than  those  of  the  genitals.  Trauma  or  infection 
of  the  nerve  periphery  of  any  abdominal  visceral  system  deranges  the 
peristalsis,  absorption,  secretion,  sensation  of  the  other  abdominal  systems. 
The  connection  between  diseases  of  the  tractus  genitalsis  (uterus)  and  tractus 
intestinalis  (stomach)  is  profound  and  intimate.  Disease  of  the  uterus  and 
stomach  frequently  coexist.  A  differential  diagnosis  of  the  symptoms  arising 
from  nephroptosia,  from  genital  ptosis  or  from  gastroptosia  is  often  difficult, 
as  similar  symptoms  may  be  referable  to  any  one  of  these  visceral  tracts.  This 
may  be  due  first  to  the  nerve  tract,  the  center  of  which  is  not  in  the  brain  or 
spinal  cord  but  in  the  sympathetic  nervous  system — (e.  g.,  cerebrum  abdom- 
inale  or  cerebrum  pelvicum).  From  reflex  action  symptoms  arise  which 
relate  to  kidney,  stomach  or  uterus.  The  reflex  tracts  being  anastomosis 
ovarica,  anastomosis  pudendo-haemorrhoidalis,  anastomosis  genito-gastrica, 
anastomosis  cutaneo-cavernosa,  anastomosis  collateralis  and  the  nervi 
splanchnic!.  Also  the  anastomosis  utero-coeliaca,  anastomosis  utero-cerebro- 
spinalis,  anastomosis  reno-coeliaca.  The  immediate  routes  of  the  reflex  are 
direct  connections  of  the  vagus  (excluding  the  ganglion  abdominales)  with  the 
sympathetic  nervous  system.  The  second  manner  in  which  the  mistakes  may 
occur  are  due  to  dislocation  of  the  respective  organs.  As  splanchnoptosia  is 
a  general  disease,  local  operation — viscero-pexy — as  nephro-pexy,  hystero- 
pexy, hepato-pexy,  gastro-pexy,  colo-pexy,  will  evidently  be  of  limited  value. 

In  diagnosis  the  patient's  trunk  should  be  divested  of_clothing.  Respir- 
ation should  be  observed  in  both  the  erect  and  prone  attitude.  Every 
abdominal  organ  should  be  palpated  in  the  erect  and  prone  attitude. 
Glenard's  belt  test  may  be  employed.  Inspection,  palpation,  percussion, 
gastric  distension  and  colonic  inflation  are  decisive  aids  to  diagnosis. 

Splanchnoptosia  is  congenital  disease  attacking  the  abdominal  and 
thoracic  viscera.  Observers  associate  with  splanchnoptosia  other  stigmata  as 
exopthalmic  goiter,  myxoedema,  neurosis,  defective  physical  form,  Stiller's 
floating  rib.  It  begins  in  disordered  function — pathologic  physiology — and 
structure  of  the  tractus  respiratorius.  Man  must  be  considered  to  possess 
respiratory  muscles  in  whatever  location  the  spinal  nerves  supply  the 
thoracic  and  abdominal  wall.  The  intercostal  (thoracic)  and  lumbar 
(abdominal)  nerves  are  not  sharply  separated  in  function.  Man's  muscular 
trunk  is  a  respiratory  apparatus.  The  diaphragm  is  the  most  important 
organ  in  splanchnoptosia.  The  splanchnoptotic  is  mainly  a  neurotic  (and 
hysteria  if  not  present  thrives  well).  Mechanical  reposition  of  organs 
through  therapy  applied  to  the  abdominal  wall  rapidly  ameliorates  the 
symptoms  and  that  is  the  general  rational  treatment.  The  symptoms  of  the 
splanchnoptotic  are  chiefly  those  of  neurasthenia  with  or  without  local 
distress  or  pain.      Pain  may  be  experienced  anywhere;  however,  it  is  chiefly 


SPLANCHNOPTOSIA  651 

referred  to  the  smaU  of  the  back.  The  first  impression  one  receives  in  study- 
ing splanchnoptosia  is  a  picture  of  multiplicity,  kaleidoscope,  dissimilars. 
However,  with  continued  investigation  the  dislocated  organs  present  them- 
selves in  groups  and  types.  In  splanchnoptosia  the  viscera  of  the  thorax, 
abdomen  and  pelvis  share  proportionally  in  the  disease. 

GENERAL  CONCLUSION  AS  REGARDS  SPLANCHNOPTOSIA. 

Splanchnoptotic  (dislocated)  organs  are  accompanied  by  more  or  less 
change  of  form  and  consequently  function.  No  dislocation  in  the  form  of  an 
organ  occurs  without  dislocation  and  change  of  form  and  relaxation  of  neigh- 
boring organs.  In  splanchnoptosia  the  change  of  form  of  organs  is  not  due 
merely  to  the  pressure  of  opposing  adjacent  organs  or  the  abdominal  wall 
(muscle  or  skeleton)  but  the  change  of  organ  form  is  due  to  function  or  to 
physiology  it  is  due  to  the  physiologic  necessity  of  visceral  motion  rhythm. 
Practically  no  organ  becomes  dislocated  without  co-existing  relaxation  of  the 
abdominal  wall.  The  dislocation  of  single  organs  does  not  occur  without 
changing  the  relations  of  adjacent  organs. 

Pathologic  Physiology. 

In  the  rise  and  progress  of  splanchnoptosia  two  matters  should  be  held 
in  view,  viz. :  (a)  pathologic  physiology,  and  (b)  mechanical  pathology. 
Pathologic  physiology  is  disordered  function  which  is  abnormal  innumerable 
times  before  the  pathologic  anatomy  is  perceptible.  It  is  true  organs  have 
a  wide  range  of  normal  physiology  but  in  splanchnoptosia  the  organs  have 
progressed  beyond  the  normal  physiologic  range  and  have  entered  the 
range  of  pathologic  physiology.  In  splanchnoptosia  the  pathologic  anatomy 
is  difficult  to  detect,  judge  and  estimate.  However,  it  is  plainly  evident  that 
the  physiology  of  the  organs  and  enclosing  walls  is  pathologic  because  the 
functions  are  going  wrong  and  it  is  the  office  of  rational  treatment  to  correct 
the  erroneous  physiology.  A  large  field  of  the  pathologic  physiology  in 
splanchnoptosia  is  mainly  mechanic — it  is  visceral  and  parietal  dislocation — 
hence  mechanical  pathology  will  demand  the  chief  consideration  in  the  sub- 
ject. First,  in  splanchnoptosia  by  appropriate  stimulation  {visceral  d)-ainagc) 
of  the  organs  affected  with  the  sluggish,  pathologic  physiology  to  normal 
maximum  action,  tolerant,  normal  physiology  is  restored.  Second  by  the 
mechanic  measure  applied  to  the  abdominal  and  thoracic  walls  the 
mechanical  pathology  is  rationally  removed. 

In  splanchnoptosia  the  linea  alba  may  be  elongated  and  expanded, 
stretched  to  a  thin  blade. 

In  splanchnoptosia  the  organs  should  be  first  palpated  in  the  horizontal 
or  prone  position  and  the  outline  marked  with  colored  chalk,  later  in  the 
erect  position  whence  the  difference  in  location  of  the  viscera  is  plainly 
evident  during  the  horizontal  and  erect  attitude.  The  percussion  should  be 
executed  both  in  the  standing  and  lying  position  and  in  each  case  the  organs 
outlined  with  colored  chalk. 

Umbilicus.  A  test  of  splanchnoptosia  is  the  change  of  position  of  the 
umbilicus   on   coughing    while   standing   and   while    lying.     With    pendulus 


652  THE  ABDOMINAL  AND  PELVIC  BRAIN 

abdomen  the  umbilicus  moves  proximalward  while  standing  and  coughing 
but  not  while  reclining.  The  amount  of  proximalward  movement  of  the 
umbilicus  is  an  index  to  the  degree  of  splanchnoptosia.  If  the  proximal  half 
of  the  rectus  abdominalis  be  relaxed  the  umbilicus  moves  distalward.  In 
coughing  while  in  the  most  erect  attitude,  the  proximal  half  of  the  rectus  is 
contracted  and  hence  the  umbilicus  moves  proximalward.  To  make  a 
diagnosis  of  splanchnoptosia  the  patient's  clothing  should  be  removed  from 
the  trunk. 

The  symptoms  of  splanchnoptosia  may  be  grouped  into  three  phases, 
viz. :  (a)  the  prodromal  phase  in  which  arises  neurasthenia,  hysteria  hypo- 
chondria. They  are  subjective  symptoms.  Visceral  dislocation  and  relaxed 
parietes  may  be  insufficiently  advanced  to  diagnose.  However,  in  this  first 
stage  the  viscera  becomes  dislocated  and  the  parietes  become  relaxed,  the 
intra-abdominal  pressure  becomes  reduced.  In  this  phase  the  circulation 
(lymph  and  blood)  begins  to  be  compromised,  as  well  as  visceral  channels; 
secretions  are  diminished  and  toxic  absorption  becomes  evident. 

(b)  The  second  stage  of  splanchnoptosia  is  characterized  by  dyspepsia, 
constipation,  colic,  headache,  dizziness,  insomnia,  weakness,  loss  of  flesh, 
marked  visceral  dislocation  and  relaxation  of  muscular  parietes.  Anaemia, 
tympany  and  foecal  stagnation  exist.  Lack  of  intra-abdominal  pressure  is 
marked.     The  visceral  ligaments  are  elongated. 

(c)  The  third  stage  of  splanchnoptotic  symptoms  are  characterized  by 
multiple,  many  sided  subjective  symptoms.  The  clinical  picture  is  pro- 
nounced, body  weight  diminishes,  capacity  for  nourishment  is  at  a  minimum, 
muscular  weakness  is  at  a  maximum  with  scarcely  sufficient  capacity  of  forc- 
ing stool  through  the  rectum.  Functional  anuna  and  psychical  changes  may 
exist.  Sensation  is  blunted.  Glandular  secretions,  absorptions  and  visceral 
peristalsis  are  extremely  deranged.  Symptoms  become  manifold,  and  the 
patient  is  a  pathologic  picture. 

The  treatment  of  splanchnoptosia  is: 

I.  Medical  (hygienic  regulation  of  visceral  function,  diet,  habitat,  avoca- 
tion). 

The  medical  treatment  for  splanchnoptosia  is  by  means  of  ample  visceral 
drainage  of  the  tractus  intestinalis  and  tractus  urinarius  which  increases  the 
volume  of  fluid  in  the  lumen  of  the  tractus  vascularis  and  tractus  lymphaticus, 
effectually  sewering,  draining  the  body  of  waste  laden  material.  It  is 
visceral  drainage,  appropriate  food,  ample  rest. 

II.  Mechanical  (forcible  reposition  and  maintenance  of  viscera  in  their 
normal  physiologic  position — i.  e.,  on  their  visceral  shelves  and  in  their 
visceral  fossae).  j 

The  mechanical  treatment  consists  in  the  employment  of  abdominal 
binders,  especially  Achilles  Rose  adhesive  strapping  (being  rational,  econom- 
ical and  practical).  The  straps  do  not  slip.  Also  the  author's  abdominal 
binder  within  which  is  placed  a  pneumatic  rubber  pad  which  can  be  distended 
with  air  to  suit  the  patient's  comfort.  The  splanchnoptotic  must  make  the 
best  of  his  hereditary  burden  and  assume  as  much  (horizontal)  rest  as 
possible. 


SPLANCHNOPTOSIA  G53 

777.  Surgical  (superposition  of  the  abdominal  wall,  viscero-pexy  anas- 
tomosis.) 

The  surgical  treatment  consists  of:  (a)  viscero-pexy,  i.e.,  fixation  of 
mobile  viscus  to  the  abdominal  wall  (extremely  limited,  as  it  attempts  to  cure 
one  alleged  visceral  lesion — excessive  mobility — by  producing  another — 
visceral  fixation).  (b)  Diminishing  the  abdominal  cavity  and  forcing  the 
mobile  organs  on  their  visceral  shelves  and  visceral  fossae  by  superposition 
(overlapping)  the  elastic,  fascio-muscular  apparatus  of  the  abdominal  wall 
like  a  double  breasted  coat  (rational,  practical),  (c),  Anastomosis  as  gastro- 
enterostomy. 

Some  of  the  photographs  in  this  chapter  were  executed  by  Dr.  William 
E.  Holland,  from  my  wall  charts. 

A  PARTIAL  BIBLIOGRAPHY  OF  SPLANCHNOPTOSIA 

Rudolph  Virchow — Virchow's  Archiv.,  vol.  V,  1853.     An  historical,  critical  and  exact  con- 
sideration of  the  affections  of  the  abdominal  cavity. 
Aberle,  Rallet,  Rayer,  J.  B.  Morgazni,  Kusmaul,  Bayer,  Hertzka,  Lindner. 
Fischer-Benyon,    Becker   and     Lenhoff,  Frickhinger,  Kuttner,  Strauss,  Chvostek,  Memert, 

Kelling,  Huber,  Flemer,  Hufschmidt,  Ewald,  Bruggemann,  B.  Stiller,  Bial,  Obvortzow, 

Boaz,  Ostertag. 
Frantz  Glenard — Articles  from  1885  to  1906.     Book  on  splanchnoptosia  (875  pages)  published 

in  18 
Theodore  Landau — Wander  Nieve,  1881. 
Theodore  Landau — Wander  Leber,  1887. 
C.  Schwerdt — Beitrag  (splanchnoptosia),  1807. 
J.  G.  Sheldon — Is  Nephroptosis  Hereditary?  1903. 

Byron  Robinson — Gastro-duodenal  Dilatation,  Cincin-Lancet-Clinic,  Dec.  8,  1900. 
A.  W.  Lea — Enteroptosis,  Medical  Chronicle,  1902. 
Saunby— British  Med.  Jr.,  Nov.  29,  1902. 
Beyea— Pennsyl.  Med.  Jr.,  Nov.,  1902. 

Charles  Adron — Splanchnoptosia  in  Pregnancv,  Am.  Jr.  Surg,  and  Gvnecol.,  July,  1902. 
A.  P.  Francine— Gastroptosis,  Philadel.  Med.  Jr.,  Jan.  3,  1903. 
J.  D.  Steele — Analyses  of  70  cases  of   gastroptosis,  Am.  Jr.  Med.  Assn.,  Nov.  8,  1902,  also 

Jan.  25,  1902. 
R.  C.  Coffey — A  method  of  suspending  the  stomach,  Philadel.  Med.  Jr.,  Oct.  11,  1902. 
Earnest  Gellant — The  Rational  Treatment  of  movable  kidney  and  associated  ptosis,  Am.  Jr. 

Surg,  and  Gvnecol.,  Dec,  1902,  N.  Y.  Med.  Jr.,  April  29,  1905. 
Robert  J.  Reed— Movable  Kidney,  Philadel.  Med.  Jr.,  Nov.  8,  1902. 
L.  Schoeler — Movable  Kidney,  Virg.  Semi-Med.  Monthly,  April  14,  1899. 
J.  E.  Moore — Splanchnoptosis  from  a  surgical  standpoint,  Jr.  Am.  Med.  Assn.,  July  29,  1905. 
O.  Kraus — Emfluss  des  Korsetts,  1904. 

H.  Quincke — Enteroptose,  Therapic  de  Gegenwart,  XLIV,  page  538. 
H.  A.  McCullum— British  Med.  Jr.,  Feb.  18,  1905. 

Thomas  R.  Brown — Enteroptosis,  American  Medicine,  July  and  August,  1903.    Three  articles. 
C.  A.  Meltzurg — Enteroptose  und  Intra-abdominales,  Druck,  1898. 
Byron  Robinson— Splanchnoptosia,  Philadel.  Med.  Jr..  Nov.  30,  Dec.  7,  1901. 
J.  M.  Taylor — The  Rational  Treatment  of  visceral  ptosis,  N.  Y.  Med.  Jr.,  Aug.  4,  1906. 
J.  N.  Le  Conte— Gastroptosis,  N.  Y.  Med.  Jr.,  July  25,  1903. 
Arthur  Keith — Hunterian  Lectures,  Lancet,  March  7,  1903. 
L.  Krez — Frage  der  Enteroptose,  1892. 

H.  Goelet — Annals  of  Gynecology  and  Pediatry,  vol.  XV,  1903. 
M.  L.  Harris— Movable  Kidney,  Jr.  Am.  Med.  Assn.,  June  1,  1901,  Feb.  13,  1904. 
C.  A.  Meltzurg— Gastroptose,  Wiener  Med.  Presse,  Julv  28,  Aug.  4,  Aug.  11,  Aug.  18,  Aug.  25, 

1895. 
J.  Chalmers  Da  Costa — Xephroptosia,  N.  Y.  Med.  Jr.,  Aug.  4,  1906. 
Agness  C.  Vietor — Splanchnoptosia,  Boston  Med.  and  Surg.  Jr.,  Aug.  9,  Sept.  9,  1906. 
Achilles  Rose  and  R.  C.  Kemp — Atonia  Gastrica  (Book),  1906. 
R.  Weissmann — Leber  Enteroptose,  Monograph. 


CHAPTER  XL. 

SYMPATHETIC  RELATION  OF  THE  GENITALIA  TO  THE 
OLFACTORY  ORGANS. 

One's  rainbow  of  desires  changes  color  with  the  passing  years. 

It  is  when  you  come  close  to  a  man  in  conversation  that  you  discover  what  his 
real  abilities  are. — Samuel  Johnson. 

It  is  a  curious  fact  that  even  laymen  have  for  ages  noted  that  the  organ 
of  smell  is  closely  related  to  the  generative  organs,  but  it  is  very  recently 
that  specialists  (gynecologists  and  rhinologists)  are  putting  together  the  con- 
nected story.  The  relation  of  the  olfactory  organ  and  nasal  mucous  mem- 
brane with  the  genitals  are  by  way  of  the  sympathetic.  The  anatomic  path 
of  travel  from  the  nasal  mucous  membrane  to  the  genitals  is  through  the  fifth 
cranial  nerve,  or  trigeminus,  which  is  supremely  the  ganglionic  cranial  nerve, 
It  is  the  type  of  mixed  nerves.  It  has  eight  ganglia  situated  on  its  branches. 
It  also  sends  a  large  branch  to  the  mucous  membrane  of  the  nose — the  nasal 
nerve.  T'us  will  at  once  explain  its  wide  influence  in  reflection  or  disease, 
because  of  lis  extensive  influence  over  the  caliber  of  adjacent  blood  and 
lymph  vessels,  and  the  extensive  periphery  in  the  nasal  mucosa,  allowing 
opportunity  for  numerous  reflexes. 

Let  us  examine  for  a  moment  the  ganglia  of  the  trigeminus  (trifacial  or 
fifth  cranial  nerve — the  ganglionic  nerve  of  the  brain).  A  significant  statement 
may  precede  the  short  description,  by  saying  that  one  of  the  chief  offices  of 
a  ganglion  is  to  demedullate  nerves.  1,  We  may  note  the  Gasserian  ganglion 
of  the  fifth  cranial  nerve,  situated  in  a  depression  in  the  apex  of  the  petrous 
portion  of  the  temporal  bone.  The  ganglion  is  as  large  as  the  end  of  the 
little  finger.  The  ganglionic  nature  of  this  swelling  was  perceived  by 
Raimund  Balthasar  Hirsch,  a  Vienna  anatomist,  in  1765,  who  christened  it 
the  "Ganglion  Gasserii"  in  honor  of  his  teacher,  Gasserius,  who  in  1779  was 
"Privat  Docent"  in  anatomy  under  Prof.  Joseph  Jans,  in  Vienna.  Since 
Du  Bois-Remond  announced  from  personal  experience  that  he  thought  facial 
neuralgia  was  due  to  spasmodic  contraction  of  the  blood  vessels  controlled 
by  the  sympathetic,  surgeons  have  attempted  to  cure  facial  neuralgia  by 
destruction  of  Gasser's  ganglion.  This  is  at  least  a  recognition  of  the 
sympathetic  nature  of  the  Gasserian  ganglion,  and  its  consequent  influence 
over  the  caliber  of  the  blood  vessels. 

The  Gasserian  ganglion  has  close  and  intimate  connection  with  the 
sympathetic  nerves.  The  blood  vessels  alone  which  are  necessary  to  supply 
the  Gasserian  ganglion  would  produce  a  close  and  intimate  relation  between 
the  sympathetic  and  trifacial.  The  trigeminus  shows  a  very  intimate  and 
extensive  connection  with  the  tonsils,  the  sebaceous  glands  of  the  face  and 

654 


RELATION    Of  GENITALIA    TO   OLFACTORY   ORGANS      655 

genitals.  This  is  seen  at  puberty  of  both  boys  and  girls  (facial  acne),  and 
in  the  menopause.  The  changes  in  voice  of  boys  at  puberty,  and  the  changes 
of  voice  of  women  at  the  monthly,  may  be  easily  worked  out  anatomically,  by 
dissecting  out  the  connection  between  the  superior  cervical  ganglion  and  the 
pneumogastric  and  glossopharyngeal.  Also  the  spheno-palatine  sends 
branches  to  the  tonsils  in  the  descending  palatine  nerves.  One  may  find 
from  three  to  five  branches  of  nerves  passing  from  the  superior  cervical  gan- 
glion to  the  glosso-pharyngeal  and  pneumogastric  nerves.  During  menstrua- 
tion the  vocal  cords  are  congested  and  hence  the  hoarse,  husky  voice;  and  a 
similar  but  permanent  physiological  process  of  congestion  and  growth 
occurs  in  the  boy  at  puberty.  Hence  the  close  and  intimate  relations  of  the 
vocal  cords  (voice)  and  nasal  mucosa  (smell)  and  reflex  action  with  the  genitals, 
have  a  distinct,  concrete,  anatomical  explanation.  Besides,  the  larynx  is 
supplied  by  the  sympathetic  branches  which  accompany  the  superior  and 
inferior  recurrent  laryngeal  nerves. 

2.  The  ophthalmic,  lenticular  or  ciliary  ganglion  is  a  pinhead  sized  gan- 
glion situated  in  the  orbit.  It  is  closely  connected  by  roots  with  the  nasal 
branch  of  the  fifth  nerve,  i.  e.,  has  relations  with  the  nasal  mucosa,  by  a 
sympathetic  branch  from  the  cavernous  plexus.  It  is  also  connected  with 
the  third  cranial.  This  second  ganglion  has  intimate  connections  with  the 
nasal  mucosa.  Joseph  Guiscard  Duverny  (1648-1730),  a  French  anatomist, 
discovered  this  ganglion. 

3.  The  spheno-palatine,  or  Meckel's  ganglion,  situated  in  the  spheno- 
palatine fossa  and  on  the  superior  maxillary  branch  of  the  trifacial,  is  a  large 
mass  of  nerve  cells.  It  is  intimately  connected  with  the  nasal  mucosa  by  the 
descending  palatine  nerves.  The  spheno-palatine  ganglion  was  discovered 
and  described  by  Johann  Friednch  Meckel  (1717-1774),  a  celebrated  German 
anatomist.  Like  all  the  other  ganglia  of  the  fifth  cranial  nerve,  it  possesses 
motor,  sensory  and  sympathetic  roots.  It  sends  a  considerable  nerve  supply 
to  the  tonsils.  Hence  we  again  observe  that  this  ganglion  shares  in  distribut- 
ing nerves  to  the  nasal  mucosa  and  the  region  of  the  tonsils.  But  the  premise 
of  our  argument  is  that  the  fifth  nerve,  being  studded  by  eight  sympatheic 
ganglia,  is  intimately  and  closely  connected,  anatomically  and  functionally, 
with  the  genitals.  Therefore  what  affects  the  fifth  nerve  will  affect  the  geni- 
tals, and  vice  versa. 

4.  The  optic  or  Arnold's  ganglion  is  located  just  below  the  foramen  ovale, 
on  the  inferior  maxillary  branch  of  the  trifacial.  Its  sympathetic  branches 
are  derived  from  the  sympathetic  plexuses  which  surround  the  adjacent  mid- 
dle meningeal  artery.  It  is  connected  with  the  facial  and  glosso-pharyngeal 
nerves  and  sends  branches  to  the  tensor  palati.  In  our  library  may  be  seen 
Friednch  Arnold's  "Anatomie  des  Menschen,"  3  vols.  On  page  909,  Vol.  II, 
Arnold  says,  "Der  Ohrknoten  wurde  von  mir  im  Winter  1825-26  endeckt. " 
In  English,  "'The  optic  ganglion  was  discovered  by  me  in  the  winter  of  1825- 
26."  Professor  Arnold  noted  75  years  ago  that  many  tried  in  vain  to  show 
that  others  than  himself  discovered  the  ganglion.  This  ganglion  shows  con- 
nection with  the  larynx  by  way  of  the  glosso-pharyngeal  and  tensor  palati ; 
and,  through  the  Vidian  nerve  and  Meckel's  ganglion,  with  the  nasal  mucosa. 


656 


THE  ABDOMIXAL  AXD  PELVIC  BRAIX 


5.  The  submaxillary  ganglion  is  situated  on  the  lingual  branch  of  the 
inferior  branch  of  the  trifacial  nerve.  Its  sympathetic  branch  is  derived 
from  the  plexus  which  surrounds  the  adjacent  facial  artery.  This  ganglion 
was  discovered  by  Meckel  in  1745.  It  has  been  named  after  him— Ganglion 
Meckelii  Minus.  The  ganglion  communicates  with  the  facial  or  the  seventh 
nerve. 


Fig.  207.     Nerves  of  internal  genitals,  pelvic  brain,  dissected  under  alcohol. 

6.  The  sublingual  or  Blandin's  ganglion  is  situated  on  the  branch  of 
nerves  going  to  the  sublingual  gland.  This  collection  of  nerves  may  be  only 
a  plexus  or  a  ganglion.  It  should  have  a  similar  connection  with  the  submax- 
illary ganglion.  Phillippe  Frederic  Blandin  (1793-1849).  a  French  surgeon, 
first  described  this  ganglion  in  1349. 

7.  The  ganglion  of  Bockdalek  is  located  at  the  junction  of  the  middle 
superior  dental  nerve  with  the  anterior  superior  dental  nerve.  It  is  not  con- 
stant, and  besides,  the  swelling  may  not  always  be  a  ganglion,  i.  e.,  may  not 


RELATION    OF  GENITALIA    TO   OLFACTORY  ORGANS      657 

contain  nerve-cells.  It  lies  above  the  upper  canine  tooth.  Its  discovery  is 
due  to  Victor  Alexander  Bockdalek,  Professor  of  Anatomy  in  Prague  until 
1869  (papers  published  in  1866),  and  Victor  Bockdalek,  his  son,  also  an  anato- 
mist in  Prague.  However,  it  appears  to  be  the  father  who  discovered  this 
ganglion,  previous  to  1851. 

8.  The  ganglion  of  Valentine  is  situated  at  the  junction  of  the  middle 
superior  dental  nerve  and  posterior  superior  dental  nerve.  It  is  located  above 
the  second  bicuspid  tooth.  The  ganglion  was  discovered  by  Gabriel  Gustave 
Valentine  (1810-1883),  a  German  anatomist.  All  the  ganglia  of  the  fifth 
cranial  or  trifacial  have  systematic  connections. 

We  should  have  known  that  the  trigeminus  is  supremely  the  ganglionic 
cranial  nerve;  that  it  is  closely  and  intimately  connected,  especially  with  the 
genitals  by  way  of  the  sympathetic  tracts;  also  that  the  trigeminus  is  closely 
and  intimately  connected,  especially  with  the  nasal  mucosa,  and  to  a  consid- 
erable extent  with  the  larynx  and  vocal  cords.  There  are  found  to  be  num- 
erous and  intimate  connections  between  the  fifth  cranial  nerve  (the  trigeminus) 
and  the  seventh  cranial  nerve  (the  facial).  Observation  shows  the  intimate 
relation  is  accomplished  by  means  of  the  sympathetic  nerves,  especially  the 
ganglia  on  the  trifacial.  This  physiologic  relation  of  the  genitals  to  the  tri- 
facial and  facial  nerves  may  be  plainly  observed  in  the  sexual  relations  and 
cohabitations  of  animals. 

Irritation  of  the  nasal  mucosa  will  cause  congestion  and  erection. 
Occasionally  irritation  of  the  genitals  will  cause  congestion  of  the  face  or  the 
region  of  the  trigeminus.  Urethral  irritation  will  induce  "gritting"  of  the 
teeth,  i.  e.,  action  of  the  masseter  muscles,  supplied  by  the  inferior  branch 
of  the  fifth. 

Dr.  A.  G.  Hobbs  describes  two  cases  of  severe  priapism,  accompanying 
acute  rhinitis  (Jour.  Am.  Med.  Assn.,  1897).  On  spraying  the  nasal  mucosa 
with  cocaine  the  priapism  immediately  subsided.  Opium  affected  the 
priapism  in  each  case,  but  only  to  slight  degree. 

A  reflex  sneeze  is  not  infrequent  previous  to  erection.  In  preparations 
for  coition  the  involvement  of  the  nasal  mucosa  is  quite  apparent  in  animals, 
as  the  horse,  dog,  bull,  etc.  In  monkeys  the  nasal  mucosa  is  not  only 
involved  in  coition,  but  it  is  evident  that  the  larynx  is  highly  involved,  from 
the  active  and  vigorous  chattering,  emitted  previous  to  and  during  coition. 
The  mare  neighs  at  the  approaching  of  the  stallion  or  cow  bellows  at  the 
approach  of  the  bull,  the  growling  of  dogs,  noise  of  cats  and  cackling  of  hens, 
are  doubtless  not  accidental  at  times  of  coition,  but  due  to  irritation  of 
nerve  tracts. 

The  tissue  covering  the  turbinated  bones  is  quite  erectile.  A  nasal  reflex 
will  induce  an  erectile  action  in  the  corpora  cavernosa.  We  know  that  the 
genitals  are  intimately  and  profoundly  supplied  by  the  sympathetic  nerves. 
We  know  that  the  fifth  nerve  is  supremely  the  ganglionic  (sympathetic)  nerve 
of  the  brain.  The  fifth  nerve  sends  a  rich  supply  to  the  nasal  mucosa  and  to 
the  larynx  through  the  vagus  and  glosso-pharyngeal. 

Clinically    and    anatomically   we   note   a   close    and    intimate   relation 

42 


658  THE  ABDOMINAL  AND  PELVIC  BRAIN 

between  the  genitals  and  the  nasal  mucosa,  the  larynx  and  the  sebaceous 
glands  of  the  face.  The  whole  manifestation  is  due  to  reflex  action  carried 
through  the  sympathetic  nerves.  The  frequent  hemorrhages  from  the 
nose  during  and  subsequent  to  puberty  in  both  sexes,  demonstrate  the  inti- 
mate relation  of  the  nasal  mucosa.  Again,  why  is  it  that  so  many  women  we 
note  with  chronic  uterine  disease  also  have  rhinitis  in  different  forms?  A 
typical  example  came  to  my  office  a  few  days  ago.  She  was  24  years  old  and 
single.  At  20  she  began  to  be  irregular  in  menstrual  function,  and  to  have 
menorrhagia.  Digital  examination  revealed  quite  a  large,  hypertrophic, 
metritic  uterus,  fixed  by  old  adhesions,  with  distinct  retroflexion.  She  said 
she  bled  frequently  at  the  nose.  The  tissues  covering  the  turbinated  bones 
were  thickened,  inflamed  and  congested.  Chronic  rhinitis  and  metritis  co- 
existed. 

Many  diseased  generative  organs  co-exist  with  diseased  nasal  mucosa. 
The  eight  ganglia  on  the  fifth  cranial  nerve — (1)  Ganglion  Gasser;  (2) 
Ophthalmic;  (3)  Spheno-palatine;  (4)  Optic;  (5)  Submaxillary;  (6)  Sublin- 
gual; (7)  Bockdalek;  (8)  Valentine — not  only  show  the  sympathetic  nature 
of  the  fifth  cranial  nerve,  but  also  intimate  relation  with  the  nasal  mucosa, 
larynx,  abdominal  brain,  and  especially  with  the  genitals. 

NASAL  DYSMENORRHEA. 

The  relationship  between  the  nasal  mucous  membrane  and  the  sexual 
apparatus  is  often  forgotten.  One  should  always  remember  that  there  is 
always  a  woman  behind  the  uterus.  In  cases  of  persistent  dysmenorrhea 
relief  may  sometimes  be  afforded  by  painting  the  genital  spots  in  the  nose 
with  1  per  cent  solution  of  cocaine,  as  demonstrated  by  Schift,  Emil  Ries, 
Fliess  and  others.  During  menstruation  there  is  congestion  of  the  Schneid- 
erian  membrane  not  present  during  the  rest  of  the  month;  a  congestion  which 
may  also  be  produced  by  violent  sexual  excitement — the  popular  expression 
"bride's  cold"  being  a  laity  recognition  of  the  relation  between  the  nose  and 
the  sexual  sphere.  In  most  people  there  is  a  temporary  swelling  of  the  nasal 
mucous  membrane  just  preceding  and  during  the  sexual  act,  disappearing 
with  detumescence. 


INDEX 


Suhject  Page 

Anesthesia 297 

Angina  Pectoris 313 

Appendicitis 414 

Brain,  Abdominal 

02,    112,  195,  225,  287,  300,  318 

Anatomy 112,   123 

Afferent 112 

Efferent 114 

Holotopy 54,  131 

Idiotopy 54,    115,  133 

Position 114 

Skelotopy 54,     114,    131 

Syntopy 54,      114,    131 

Ganglia 118 

Diaphragmatic ..." 118 

Splanchnica 118 

Renalia 118 

Borders 116 

Dimensions 115 

Form 115 

Surfaces 116 

Relations 122 

Genitalis 123 

Intestinalis 123 

Urinarius 123 

Physiology 123,     129,     163,   287 

Circulation 163 

Nutrition 163 

Reproduction 163 

Secretion 163 

Visceral  Automatic  Ganglia 163 

Brain,     Cranial 63,      159,    121 

Brain,    Pelvic 131-152 

Anatomy  and  Topography 131,    152 

Arrangement 135 

Borders 134 

Dimensions 133 

Fenestra 136 

Form 134 

Ganglia 138 

Ganglionic  Cells 138 

Holotopy 131 

Idiotopy 133 

Position 131 

Skeletopy 131 

Syntopy 131 

Physiology 144-156 

Age  Relation 150 

Climacterium 150,    154 

Digestive  Disturbances 175,   186 

Gestation 150,   155 

Menstruation 150,    155 

Pathological  Remarks 151 

Pubertas 150,    155 

Pueritas 150,    155 


Subject  pAGB 

Brain,  Pelvic — 
Physiology — 

Senescence 150-155 

General  Considerations 159,    180 

Rhythm 169 

Bowel  Atomy 325 

Calculus  Hepatic 314 

Cholecystitis 452 

Colonic  Appendicitis 414 

Colic  Lead 306 

Constipation 351-377 

Age  Relation 354 

Anatomy ;j,5  1 

Causes 35 1 

Diagnosis 869 

Dietetic 353 

Etiology 351 

Fluids 375 

Foods 377 

Mechanical 353 

Physiology 351 

Pathology 353 

Treatment 370 

Sex 354 

Visceral  Circulation 367 

Visceral  Drainage 375 

Fluids 375 

Foods 375 

Digestive  Tract  Disturbances 175 

Diabetes  Mellitus 314,   315 

Diabetes  Insipidus 316 

Enteralgia 304 

Entorodynia 304 

Enteromic  Appendicitis. 414 

Enteroptosia 268,  270 

Exopthalmic  Goiter 19,   20 

Gastralgia 304,   311 

Gastrodinia 304,  311 

Glycouria 315 

Ganglia 79 

Aortic   Visceral 108 

Automatic  Visceral 239,   277 

Arteriae  Phrenic 120 

Automatic  Menstrual 240,   252 

Cervical 312 

Diaphragmatic 118 

Lumbalis 79 

Oviductal 246 

Renalis 118 

Sacralis 80 

Semilunar,  Left 118 

Right 120 

Sympathetic 289,   31S 

Physiology 289 

Visceral,     Abdominal      and      Pelvic 
Brain,  Physiology 204 


659 


660 


INDEX 


Subject  Page 

Ganglia — 

Visceral,  Automatic,  Abdominal  and 
Pelvic    Brain,  Reference  to  Sexual 

Organs 227 

Genitalis,  Tractus,  Pathologic   Physiol- 
ogy  432-437 

Avocation 447 

Blood  Volume 441 

Diagnosis 440 

Prophylaxis 447 

Visceral  Drainage. 

Habitat 447 

Fluids 445 

Foods 446,   459 

Douches 472 

Fluids. 472 

Gestation 468 

Habitat 477 

Menstruation 465 

Ovulation 461 

Peristalsis 461 

Secretion 463 

Sensation 465 

Tampon 474 

Treatment 47,   480 

Gentalia,  Female 304.  341,  346,  347 

Traumatic 346 

Ovarian  Tumor  Weight 346 

Pressure  Neurosis 347 

Olfactory  Organs 654-658 

Nasal  Dysmenorrhcea 658 

Neurosis 341-350 

Puberty  . 253,  259,  342 

Menstruation 343 

Pregnancy 342 

Menopause 200,   253 

Tumors 208,  221,  356.  396,  423 

Infection 208 

Cicatrices 208 

Sexual  Crisis 227,  342 

Abdominal   and   Pelvic   Brain   with 
Automatic  Visceral  Ganglia.  .227,   239 

Genitalis,  Tractus 87 

Anatomy 87 

Interiliacus  Plexus 92 

Ovaricus   Plexus 90 

Pelvic , 94 

Rectalis 96 

Sacralis  Spinalis 92 

Uterinus,  Plexus 94 

Vaginalis,  Plexus • 96 

Vesicalis,  Plexus 96 

Physiology 98 

Peristalsis 100 

'    Rhythm 100 

Gynecological 294 

Hyperesthesia 296,   317 

Abdominal  Brain 302 

Cardiac  Plexus 312 

Cervical  Ganglia 312 

Diaphragmatic  Plexus 317 

Gastric  Plexus 311 

Hepatic  Plexus 314 

Hypogastric  Plexus 308 

Inferior  Mesentric 309 

Mucosa 297 

Mesenteric 304 

Ovarian 310 


Subject  Page 

H  yperesthesia — 

Pancreatic  Plexus 316 

Pelvic  Brain 309 

Renal 316 

Splenic  Plexus 313 

Spermatic. 310,  319 

Sympathetic 302 

Skin 296 

Secretions 32'J,   333 

Auerbach's  Plexus 329 

Billroth-Meissner 329 

Excessive 329 

Deficient 331 

Disproportionate 331 

Gastric 331 

Glands 331 

Muscular  Motion 33  1 

Nose 331 

Treatment 331 

Hysteria    Stigmata 284,    296,325 

Cutaneous 300 

Head 300 

Lumbosacral 300 

Muscular 300- 

Muscular  Stigma 298 

Neurosis 343 

Pain 300 

Peritoneal 300 

Pyschosis 298,      343,   344 

Special  Senses 298 

Stomach 300 

Treatment 300 

Stigma 284,   296 

Heberden's  Disease 312 

Hyperesthesia 296 

Hysteria 325 

Icterus 452 

Invagination 410 

Intestinalis,      Tractus,      Physiological 

Pathological 448 

Nervosis 456 

Pathologic 448 

Peristalsis : 448 

Intestinalis 62 

Anatomy 62 

Arteria  Hepatical 65 

Cceliacus 62 

Ductus  Bilus 65 

Gastricus 62,   64 

Hemorrhoidal  Plexus. 

Medius 70 

Inferior 70 

Hepaticus 64,   65 

Mesenterica  Superior  Plexus 67 

Physiology. 

Distal  End  Supply 74 

Middle 73 

Proximal 72 

Lymphatic  Tract 514,   545 

Absorption 516 

Genital ■ 123 

Intestinal 123 

Peristalsis 516 

Secretion 516 

Sensation 516 

Treatment 533 

Urinarius 1 23 

Melancholia 325 


INDEX 


661 


Subject  1 

Menopause 253,  259,  280,  314, 

Flushes 

Flashes 

Malnutrition 

Reflex  Irritation 

Sweat  Centers 

Uterine  Disturbances 

Menstruation 

Automatic  Menstrual  Ganglia 

Neurosis 

Psychosis 343, 

Premenstrual  Pain 

Nerves 

Anatomy 

Cerebral 278 

Cerebrospinal  Relation 

Genital  External 

Pelvic 

Peritoneum 

Spinal 278- 

Splanchnic 42 

Sympathetic,  Independence  of .  .  .  . 
Sympathetic.  .187,  287,  292,  294, 

Trigeminus 

Vagus , 

Vasomotor 

Visceral  Sympathetic 278, 

Pathological 

Neuralgia 307 

Cardiac 

Celica 

Diaphragmatic 

Gastric 

Hypogastric 

Hemorrhoidal 

Mesenteric 304, 

Ovarian 

Renal 

Splenic 

Urethral 

Nerves  Vascularis 103- 

Anatomy 103 

Aortic  Visceral  Ganglia, 108 

Physiology 106- 

Nerves. 

Genital 

Pelvic 

Peritoneum 

Cerebral. 298, 

Neurasthenia 

(Neurosis     Abdominalis) 495 

Absorption 

Asthenia 

Congenita 

Degeneracy  Habitus 

Heredity 

Predisposition 

Secretion 

Sensation 

Stigma ' 

Treatment 

Neurosis 267 

Enteralgia 

Gastralgia 

Hepatis 

Hysteria 

Melancholia 

Neurasthenia 


'age 

342 

256 
256 
259 
259 
256 
312 
343 
240 
343 
344 
248 
342 
290 
302 
278 
286 
278 
288 
302 
,  43 
187 
304 
342 
342 
205 
302 
281 
•317 
312 
302 
317 
311 
302 
309 
309 
310 
316 
314 
310 
■110 
-106 
-110 
-110 

286 
278 
.288 
302 
.325 
-501 
495 
496 
497 
497 
.497 
.498 
.498 
.498 
.499 
.500 
-277 
304 
.304 
.276 
.284 
325 
325 


Subject  Pace 

Neurosis — 

Oviductal 277 

Peristalsis 277 

Rectalis 277 

Renalis 277 

Uterine 277 

Visceral 267 

Neuroses,  Colon  Secretion 334 

Age 335 

Catarrh 337 

Chemical 336 

Colicky  Pains 384 

Microscopical  Examinations 336 

Motor  Neuroses 337 

Mucous  Colic 337 

Mucous  Stools 334 

Menstrual 343 

Nervous 337 

Pathology 336 

Treatment 339 

Neuroses,  Motor 318 

Anemia 322 

Abdominal  Brain 318 

Atomy  of  Bowels 325 

Auerbach's  Plexus 318 

Bilbroth-Meissner's  Plexus 318 

Cranial  Nerves 318 

Colon 334 

Enterospasm 324 

Intestinal  Movements 318 

Invagination 328 

Hysteria 284,  296,  325 

Melancholia 325 

Paralysis 325 

Sympathetic  Ganglia 318 

Spinal  Nerves 318 

Sympathetic  System 318 

Nervosus,  Tractus 495-501 

Physiological  Pathological. 

Abdominalis 495 

Absorption 496 

Secretion 498 

Sensation 499 

Treatment 500 

Neuroma 405 

Nephralgia 316 

Neurasthenia 325 

Obstructions 406,  414 

Apertures 406 

Appendicitis 414 

Bands 406 

Colonic 414 

Enteronic 414 

Invagination 410 

Pancreatic  Secretions 452 

Strangulation 406 

Volvulus 412 

Pains 393 

Abdominal 393 

Abdominal,  Sudden 393,  441 

Age 396 

Appendicular 400 

Character 397 

Gastric 399 

Nephritic 399 

Pelvic 400 

Sex 396 

Reflex 402 


662 


INDEX 


Subject  Page 

Pains — 
Reflex — 

Abscess  in  Abdominal  Wall 404 

Amygdalitis  Mastitis 404 

Appenditis 414 

Axial  Torsion  of  Viscera 424 

Complete 424 

Incomplete 424 

Biliary  Channels 418 

Embolism  with  Mesenteric  Vessels, 419 

Genitals.  .  .  . 422 

Hyperesthesia 404 

Intoxication 421 

Invagination 410 

Mesenteric  Vessels  Embolus 419 

Muscular  Rigidity 410 

Neurasthenia 325 

Pancreatic  Hemorrhage,  Acute..  .  .418 

Pyosalpinx 422 

Pleurisy 402 

Spinal  Caries 404 

Spinal  Cord  and  Hysteria 404 

Strangulation  by   Bands  through 

Apertures 419 

Strangulation 406 

Testicular 404 

Paralysis 325 

Direct 325 

Indirect 325 

Pathologic 322 

Peristalsis 322,   326 

Normal 322 

Deficient 324 

Increased 326 

Pendulum 319 

Rhythmic 318 

Roll  Motion 319 

Spinal 318 

Sympathetic  System 318 

Sympathetic  Lateral  Chain 318 

Tonic  Contractions 322 

Plexus  Aorticus  Abdominalis 46,   51 

Anatomy 46,    49,    76,    78,  98 

Ganglia 46,  48 

Nerve  Trunks  and  Cords 48,  49 

Physiology 49,    51,    71,  76 

Age  Relation 59 

Interiliac  Vasomotor 52 

Interiliacus  Truncus  Plexus 56 

Interiliacus,  Distal  End 58,  92 

Utility  in  Practice 60 

Arteria  Uterinae 80 

Cceliacus 62,  64 

Communis  Arterie 80 

Gastricus 63,  64 

Genital 87 

Ganglia  Lumbales 79 

Hemorrhoidal 70 

Medium 70 

Inferior 70 

Hypaticus 62,    64,  65 

Hypogastricus 80,  308 

Iliacus  Communis  Arteriae 82,  92 

Lienalis 62,  68 

Mysentericus 69 

Inferior 69,  80 

Superior 67 

Ovaricus 78,    90,  310 


Subject  Page 

Plexus  Aorticus  Abdominalis — 
Physiology — 

Pelvic  Brain 94 

Rectalis 96 

Renalis 76 

Sacralis  Spinalis 92 

Sacralis 81 

Supra  Renalis 76 

Ureteris 78 

Urethralis 81 

Uterinus 94 

Vaginal 96 

Vesicalis 96 

Pathological 546-549 

Pathogenesis 552 

Polyuria 316 

Pregnancv 342 

Psvcosis.'. 342,  344 

Puberty 253,   259,  342 

Respiratorious 548,     569,  648 

Sexual  Crisis 342 

Shock 382-392 

Diagnosis 388 

Etiology 384 

Historv 382 

Pathology 386 

Prevention 391 

Prognosis 389 

Symptoms 387 

Treatment 390 

Spinal  Segment 567 

Strangulation 406 

Splanchnoptosia  (Atonia  Gastrica)  546-653 

Adhesions 556-574 

Mesocolic 574 

Mesoduodenal 573 

Mesogastric 573 

Mesenteronic 574 

Omental 556 

Peritoneal 556 

Bibliography 653 

Physiology  and  Anatomy. .    .   553,  559 

Circulation 626 

Colon,  Right .  .574 

Diaphragm 565,  566 

Factors 555 

Etiological 555 

Fixation  and  Motion  of  Thoracic 

Viscera 568,  569 

Fixation  of  Intestinal  Tract 572 

Mechanism 557 

Radix  Mesenterica 570 

Relaxation 561 

Segment,  Spinal 567 

Theory,  Keith's 554 

Pathological  Relations 546 

Clinical 551 

Embryologv 511 

Genitals...' 564,    617,  648 

Historical 548 

Intestinalis 562,     575,  648 

Lymphaticus 648 

Nervosus 630,    631,    648 

Pathogenesis 552 

Respiratorius 548,     569,  648 

Urinarius 564,  594,  648 

Vascularis 648 

Coloptosia 590,  591 


INDEX 


663 


Subject  Page 

Splanchnoptosia  (Atonia  Gastrica)  — 
Coloptosia — 

Symptoms 591 

Treatment      592 

Fnteroptosia 593 

Fixation 017 

Flexure  Coli  Hepatica 623 

Flexure  Coli  Lienalis 624 

Castroptosia 576 

Dilitation 582 

Diagnosis 583 

Etiology 580 

Respiration    577 

Treatment 584 

Gastro-Duodenal  Dilatation 004 

Diagnosis 611 

Treatment 612,  617 

Genitals 504,  017.  619,   648 

Fixation 617 

Respiration 618 

Hepatoptosia 268,  274,  586 

Diagnosis 588 

Etiology 587 

Frequency 587 

Fixation  of  Liver 586 

Movements,  Respiratorv 586 

Treatment ' 589 

Nephroptosia o'.)4,  603 

Age 597 

Diagnosis 597 

Etiology 597 

Fi  xation 594 

Frequenev 597 

Relation 595 

Respiration 594 

Robinson,  Byron,  Triangle 602 

Symptoms .  .     

Treatment 603 

Neuroses 630,    631,  648 

Frequency 632 

Symptoms . 632 

Treatment 634 

Sympathetic   Nerve    

39,     187,   287,  292,   294.  304 

Absorption 187,     188 

Anatomy  and  Physiologic   Anat- 
omy  33,  38,    192,    203,  290 

Automatic      Menstrual      Gang- 
lia  240:     252 

Cervical 40 

Circulation   187 

Classification  of  Diseases  .  .  .  .28,  32 
Considerations  for  Removal  of 

Tumors    206.   226 

Dorsal 42 

Growth 187 

Gvnecology 175,  292 

Historical  Sketch    .     11.   27 

Independence    of    Sympathetic 

187,   192 

Macroscopic  21,   26 

Microscopic     26,  27 

Nutrition 187 

Pathology    in    Gynecology 292 

Pelvic    44 

Peristalsis 188 


Subject  1jagb 

Splanchnoptosia  (Atonia  Gastricaj — 
Sympathetic  Nerve  — 
Anatomy — 

Physiology  of  Abdominal  and 
Pelvic  Brain  with  Automat- 
ic Visceral  Ganglia 204,   207 

Relation  to  Cerebrospinal 278 

Sacral 44,  45 

Secretion 187 

Sensation 188 

Thoracic 42,  43 

Trunks  of 39,  45 

Uterine  Changes 17.") 

Vasomoter  Nerves. 205 

Pathologv,    187,    287,    292,    294,    304 

Tumors 221 

Axial   Rotation 

221,    324,  356,    396,  425 

Reflex  Action  on  Sympathetic.  .  208,   226 

Kidney 'A\7 

Urinarius 76,     80,     98,123 

Anatomy 76 

Arteria  Uterina 80 

Arteria  Communis.  . 80 

Ganglia  Sacrales 80 

Ganglia  Lumbales 79 

Hypogastrics 80 

Mesentericus  Inf 80 

Mesentericus  Sup    80 

Ovaricus  (Spermaticus) 78 

Renahs 16,  78 

Renalis  Superior 76 

Sacralis 81 

Uretens 78 

Urethrahs 81 

Vesicales 80 

Urinarius, Tractus,  Phvsiological  Patho- 
logical  ' 479-494 

Absorption 483 

Peristalsis 479 

Secretion 481 

Sensation 485 

Treatment 489 

Uremia 404 

Urinary  Colic.     .       419 

Vascularis,  Tractus 502 

Pathologic    Physiology  of    .  .  .  .502,   513 

Combined  Treatment 

Excessive  Secretion 506 

Deficient 506 

Disproportionate    .  506 

Peristalsis 503 

Excessive 503 

Deficient 503 

Disproportionate 503 

Vascular  Tract    502 

Visceral  Drainage  by  Fluids 507 

Visceral  Drainage  by  Foods 507 

Pathologic  Physiology  of  the  Blood,  509 
Red  Blood  Corpuscles  and  Hem- 

aglobin 509 

Plasma  (Liquor  Sanguinis) 512 

Pathologic  Anatomy 513 

Treatment 512 

White  Blood  Corpuscles 511 

Vascularis 648 

Volvulus 412 


LIST  OF  ILLUSTRATIONS 


No.  '                                                                                                                                   Page 

1  An  Illustration  of  the  Sympathetic  Nerve 13 

2  An  Illustration  of  the  Abdominal  Sympathetic  Nerve  of  the  Male 29 

3  A  Diagram  of  Sympathetic  from  Proximal  to  Distal  End 34 

4  Abdominal  Brain,  Lumbar  Lateral  Chain 35 

5  Lumbar  and  Sacral  Portions  of  the  Sympathetic 37 

6  Trunk  of  the  Vasomotor 41 

7  Plexus  Aorticus  Abdominalis 47 

8  Plexus  Aorticus  Abdominalis 50 

9  Plexus  Interiliacus 53 

10  Plexus  Interiliacus  of  Adult 55 

1 1  The  Vasomotor  Interiliacus  Plexus 57 

12  Plexus  Interiliacus  of  Adult 59 

13  The  Nerves  of  the  Tractus  Intestinalis 63 

14  Anastomosing  Arteries  of  the  Tractus  Intestinalis 67 

15  Nerves  of  the  Hepatic  Artery  and  Biliary  Duct 69 

16  Arteries  of  Ccecum  and  Appendix 71 

17  N-ray  of  Ductus  Pancreaticus  and  Part  of  Ductus  Bilis 73 

18  Arterial  Supply  of  Tractus  Urinarius 77 

19  Nerves  of  Tractus  Urinarius,  Corrosion  Anatomy 79 

20  Corrosion  Anatomy  (Hyrtl's  Exsanguinated  Renal  Zone)     81 

21  Nerves  of  Tractus  Urinarius 83 

22  Corrosion  Anatomy 84 

23  Relation  of  Spinal  Nerves  at  Tractus  Urinarius 85 

24  Nerves  of  Tractus  Genitalis 89 

25  Nerves  of  Tractus  Genitalis,  Pregnant  about  Three  Months. . .    91 

26  Genital  Nerves  of  Infant 93 

27  Genital  Nerves  of  Adult 95 

28  The  Nerves  of  the  Tractus  Genitalis 97 

29  The  Arterial  Circulation  of  the  Puerperal  Uterus  99 

30  Circles,  Arcs  and  Arcades  of  the  Abdominal  Arterie- 105 

31  Nerves  Accompany  the  Arteries 107 

32  Nerves  of  the  Blood-vessels 109 

33  Abdominal  Brain 113 

34  Abdominal  Brain 117 

35  Abdominal  Brain 119 

36  Abdominal  Brain 121 

37  Abdominal  Brain 125 

38  Ganglion  Cells  in  the  Abdominal  Brain 127 

39  Abdominal  Brain  of  an  Infant 132 

40  Pelvic  Brain 137 

41  Pelvic  Brain  of  an  Adult 143 

42  Pelvic  Brain  149 

43  Pelvic  Brain  153 

44  Pelvic  Brain  of  an  Adult . .  157 

45  Cardiac  Nerves 162 

46  Abdominal  Brain  and  Coeliac  Axis 166 

47  Pelvic  Brain 170 

48  Ductus  Bilis  and  Ductus  Pancreaticus 174 

49  Corrosion  Anatomy  of  the  Kidney 178 

50  Ductus  Pancreaticus  with  Part  of  Ductus  Bilis 182 

51  Corrosion  Anatomy,  Uterus,  Oviducts  and  Ovary  of  New-born  Infant 185 

52  Abdominal  Brain  and  Plexus  Aorticus 194 

53  Ductus  Bilis  and  Ductus  Pancreaticus  et  Aorta  Hepatica 196 

54  Nerves  of  the  Heart 198 

55  Renal  Vascular  Supply 200 

664 


LIST  OF  ILLUSTRATIONS  665 

No.  pACe 

.r>U     Nerves  of  the  Tractus  Genitalis 202 

.r)7     Schemic  Drawing  of  the  Sympathetic  Nerve 209 

58  Pelvic  Brain , 243 

59  A  Schematic  Drawing  of  the  Sympathetic  Nerve '  254 

60  Lumbar  and  Sacral  Portions  of  the  Sympathetic  (Sappey) 260 

6 1  Sympathetic  Nerve  in  Lumbar  Region 263 

62  Sacral  Sympathetic  and  Sacro-spinal  Nerves 273 

63  Cervical  Ganglia 275 

64  Cutaneous  Nerves  of  Thorax  and  Abdomen 281 

65  Ventral  Division  of  Dorsal  Nerves 283 

66  Sympathetic,  from  Life-size  Chart  Sympathetic 285 

67  Sympathetic,  from  Life-size  Chart  Sympathetic 287 

68  Nerves  of  Non-pregnant  Uterus 287 

69  Life-size  Chart  of  Sympathetic 291 

70  Plan  of  Dorsal  Nerve 295 

71  Diagram  of  Lumbar  and  Pelvic  Plexus 297 

72  Abdominal  Brain 299 

73  Corrosion  Anatomy  of  Ductus  Bilis 303 

74  Corrosion  Anatomy  of  Kidney 307 

75  X-ray  of  Ductus  Pancreaticus   and  Part  of  Ductus  Bilis 311 

76  X-ray  of  Ductus  Bilis  et  Pancreaticus  with  Arteria  Hepatica 315 

77  Nervus  Vasomotorius 321 

78  Dilated  Ductus  Hepaticus , 324 

70     Nerves  of  the  Internal  Genitals 326 

80  Ductus  Bilis  et  Ductus  Pancreaticus 330 

81  Cross-section  of  Ureter 332 

82  X-ray  of  Ductus  Bilis  et  Ductus  Pancreaticus 357 

83  X-ray  of  Ductus  Pancreaticus  et  Ductus  Bilis 365 

84  X-ray  of  Ductus  Pancreaticus  et  Ductus  Bilis  of  Horse 373 

85  Strangulation  of  the  Sigmoid  by  Band  Originating  from  Bilateral  Pyosalpinx 394 

86  Hernia  of  Eight  Feet  of  Enteron  in  Fossa  Duodeno-Jejunalis 395 

87  Hernia  in  Fossa  Duodeno-Jejunalis 397 

88  Invagination  of  Ileum 398 

89  Ileo-Coecal  Invagination 399 

90  Progressive  Steps  of  Uterine-invagination  . .    401 

91  Complete  Uterine  Invagination 403 

92  Volvulus  of  Sigmoid 404 

93  Volvulus  of  Sigmoid i 405 

94  Volvulus  of  Ileo-Ccecal  Apparatus 406 

95  Enteronic  Volvulus 407 

96  Volvulus  of  Ileo-ccecal  Apparatus 408 

97  Position  of  the  Appendix 409 

98  Potential  Position  of  Appendix 411 

99  Absence  of  Appendix  (and  Coecum) 413 

100  Appendix  Lying  Adjacent  to  Meckel's  Diverticulum 414 

101  Relation  of  Appendix  to  the  Genital  Tract 415 

102  Nondescended  Appendix 417 

103  Biliary  Calculus  Dislodged  from  Meckel's  Diverticulum 419 

104  X-ray  of  the  Ductus  Pancreaticus   and  Part  of  Ductus  Bilis 421 

105  Specimen  Containing  Pancreaticus  Calculus 423 

106  Hepatic  Calculus  in  Hartman's  Pouch  (S)  and  Vater's  Papilla 426 

107  Carcinoma  Completely  Obstructing  the  Biliary  and  Pancreatic  Ducts 427 

108  Ureteral  Calculi 428 

109  Calculus  in  Ureter 429 

110  The  Arteria  Uterina  Overica  Three  Hours  after  Parturition  at  Term 430 

111  Hyrtl's  Exsanguinated  Renal  Zone 436 

112  Corrosion  Anatomy  Kidney 440 

113  Hyrtl's  Exsanguinated  Renal  Zone 441 

114  Lymph  Glands  in  Course  of  Blood  Vessels 444 

115  Abdominal  Brain  and  Coeliac  Plexus 451 

116  X-ray  of  Ductus  Bilis  and  Ductus  Pancreaticus 454 

117  Duodenum  with  Its  Two  Ducts — Biliary  and  Pancreatic 456 

118  X-ray  of  Ductus  Bilis,  Ductus  Pancreaticus  and  Arteria  Hepatica 458 

119  Pelvic  Brain  (adult) 462 

120  Arterial  Circulation  of  the  Puerperal  Uterus 464 

121  Transverse  Longitudinal  Section  of  Uterus 467 

122  Pelvic  Brain  in  Relation  to  the  Nervus  Vasomotorius 469 

123  Arteries  of  Puerperal  Uterus 471 

124  Histology  of  Pelvic  Brain 473 


666  LIST  OF  ILLUSTRATIONS 

No.  .       .  Pace 

125  Tractus  Vascularis  and  Tractus  Nervosus  of  the  Tractus  Genitalis 475 

126  Pelvic  Brain 476 

127  Sacro-pubic  Hernia 477 

128  Intimate  Relation  of  the  Tractus  Genitalis  and  Tractus  Urinarius 480 

129  Illustration  of  the  Female  Urinary  Tract 482 

130  An    Illustration   of   the   Abdominal    Sympathetic    Nerve  of   the   Male,  Especially 

Representing  the  Nerves  of  the  Tractus  Urinarius     484 

131  Nerve  Supply  Tractus  Urinarius 486 

132  Nerves  of  the  Tractus  Urinarius,  Corrosion  Anatomy    487 

133  Nervus  Vasomotorius  of  the  Tractus  Urinarius 488 

134  Corrosion  Anatomy  (Hyrtl's  Exsanguinated  Renal  Zone) 489 

135  Nervus  Vasomotorius  in  Relation  with  the  Tractus  Urinarius 490 

136  Nervus  Vasomotorius  of  the  Tractus  Urinarius  (Congenitally  Dislocated) 492 

137  Relation  of  Plexus  Lumbalis  to  Tractus  Urinarius 493 

138  Nerves  of  the  Internal  Genitals 499 

139  Lymphatics 505 

140  Ductus  Thoracicus  Dexter  et  Sinister 515 

141  Lymphatics  of  Head  and  Neck 516 

142  Lymphatics  Ensheathing  a  Vein 517 

143  A  Lymphatic  Gland  with  Its  Afferent  and  Efferent  Vessels 518 

144  Lymph  Vessels  of  the  Tracheal  Mucosa 519 

145  Inguinal  Glands  of  Lymphatics 520 

146  Lymphatics  of  the  Internal  Genitals 521 

147  Lymph  Channels  and  Glands  Draining  the  Tractus  Genitalis  (Savage) 522 

148  Lymph  Channels  Draining  Cervix  and  Vagina  (Poirier) 523 

149  Lymph  Channel  (A.  A.)  of  Pyloric  End  of  Rabbits 524 

150  Transition  of  Lymph  Capillaries  into  Lymph  Trunks  with  Valves— Sacculations. .  525 

151  Lymph  Channels  and  Glands  of  the  Mesenteron  (Hoenir) 526 

152  Lymphatic  Drainage  of  Diaphragm 527 

153  Profile  View  of  the  Ductus  Thoracicus 528 

154  Lymph  Channels  in  the  Peritoneum  528 

155  Lymphatics  from  Enteron  of  Guinea  Pig  with  Plexus  Myentericus  of  Auerbach 

(Frey) • 526 

156  Rectal  Glands  and  Lymphatics ^ 

157  Stomata  Vera  Connecting  the  Peritoneum  with  the  Subperitoneal  Lymph  Channels,  ool 

158  Lymph  Glands  with  Vasa  Efferentia  et  Afferentia  (Toldt) 532 

159  Lymphatics  of  Axilla  and  Mamma 533 

160  Ductus  Thoracicus  Sinister  et  Dexter  (Toldt) ^34 

161  Perivascular  Lymphatic  (Gegenbauer) 535 

162  Superficial  (Smaller)  and  Deep  (Larger)  Anastomosing  Lymphatics 536 

163  Lymphatics  and  Glands  of  the  Mesenteron 537 

164  The  Inguinal  Glands  Receiving  the  Rectal  and  Genital  Lymph    Channels  (Toldt) . .  o'SS 

165  Lymph  Glands  and  Channels  Relating  to  Mamma  and  Neck  (Toldt) 539 

166  Lymphatics  of  Wall  of  Enteron  of  Calf  (Injected) 540 

167  Injected  Lymphatic  Vessels  of  the  Tongue 541 

168  Lymphatics  of  the  Vermiform  Appendix 542 

169  Lymph  Vessels  of  Dog's  Stomach 543 

170  Splanchnoptotic,  a  Ventral  View 547 

171  Splanchnoptotic,  Lateral  View 54J 

172  Splanchnoptotic,  Abdominal  Walls  Removed ^50 

173  Abdominal  and  Thoracic  Organs  Separated  by  the  Diaphragm 554 

174  Dorsal  Fixation  and  Location  of  the  Mesenteries ^° 

175  Separation  and  Elongation  of  the  Recti  Abdominalis  in  Splanchnoptosia 560 

176  The  Diaphragm  (Ventro-distal  View) 561 

177  The  Diaphragm  (Dorsal  View) £°3 

178  Proximal  View  of  the  Pelvic  Floor  (Sholer) 564 

179  Distal  View  of  the  Pelvic  Floor <™> 

180  A  Normal  Transverse  Segment  of  the  Abdominal  Wall •  •  5b7 

181  A  Transverse  Section  of  the  Abdomen,  about  the  Umbilicus  of  a  Splanchnoptotic,  568 

182  Viscera  of  a  Female  Orang  from  Borneo 571 

183  Areas  of  Peritoneum -  •  572 

184  Gastro-duodenal  Dilatation.  Gastroptosia d<7 

185  Carcinoma  Completely  Obstructing  the  Biliary  and  Pancreatic  Ducts 579 

186  The  Horizontal  Stomach,  Gastroptosia 580 

187  The  Vertical   Stomach,  Gastroptosia ^81 

188  Gastroptosia <*£ 

189  Splanchnoptosia,  The  Third  Stage 58o 

190  Coloptosia 589 

191  Presents  Established  Hepatic  Dislocation 5yb 


LIST  OF  ILLUSTRATIONS  667 

No.  Page 

192  Presents  Advanced  Hepatic  Dislocation  599 

193  Common  Condition  Found  in  Multipara 602 

194  Position  of  Duodenum  and  the  Superior  Mesenteric  Artery,  Vein  and   Nerve 604 

195  Relation  with  Stomach  Drawn  Proximally 605 

196  Gastro-duodenal  Dilatation ." tin; 

197  Profile  view  of  Obstruction 608 

198  Superior  Mesenteric  Artery,  Vein  and  Nerve  Obstructs  the  Transverse  Segment  of 

Duodenum  as  it  Crosses  the  Vertebral  Column 610 

199  Gastro-duodenal  Dilatation 612 

200  Clamping  of  Duodenum  by  the  Mesenteric  Vessels 613 

201  Gastro-duodenal  Dilatation  Ending  when  the  Mesenteric  Vessels  Cross  the  Trans- 

verse Duodenum til  1 

202  Closure  of  Musculi  Recti  Abdominales  in  a  Single  Sheath 621 

203  Byron  Robinson's  Rubber  Air  Pad  for  Splanchnoptosia 623 

204  Byron  Robinson's  Rubber  Pad,  Profile  View 624 

205  Byron  Robinson's  Rubber  Pad,  Adjusted 627 

206  Placing  of  Sutures  in  Fascia  and  Muscles  of  the  Abdomen 641 

207  Nerves  of  Internal  Genitals  dissected  under  Alcohol 656 


LIST  OF  NAMES 


A 

Page 

Aberle 548 

Addison 19 

Akermann 17 

Alexander 12 

Allen 515 

Andersch 16 

Andral    276 

Arabians  11 

Aran 19 

Aristotle   11,  12 

Arnold  16,  655 

Aselli 515 

Atkinson 436,  437 

Auerbach    62,  168,  169,  241,  242,  243, 

244,  250,  260,  292,  293,  329,  354,  466,  526,  622 
Axman  16 

B 

Babler 431 

Bachat 14,  15,  16,  17,  262 

Baker    17 

Ball    17 

Bardel 276 

Barnes      3l>4 

Bartholine 514,  517 

Basch    320,  326 

Basedows    19,  30 

Basel  52 

Battey  343 

Bauhin 320,  355,362 

Baumgarten 353,  374 

Bayly 17 

Beck    Snow.  .18,  24,  25,  52,  130,  131,  156,  158 

Beclard 14 

Begbie    327 

Bell    19 

Bennett 511 

Bernard 19,38,  130,  187 

Bergan 16 

Beschomer    338 

Beuker 423 

Bichat 14,  15,  16,  17,  511 

Bidder  ...  .18,  19,  104,  168,  241,  242,  292,  439 

Bier 367,  379,  442,  502 

Bilroth 68,  78,  292,  293 

Billroth-Meissners 

62,    68,    70,    104,   318,  329,  466,   554,  622 

Bishop    169 

Blane 16 

Blandin    656 

Blumenbach  14,  17 

Bockdalek  V.  A 656,  657,  658 

Bockdalek  V 657 

Boivin 156 


Page 

Bohemian    571 

Bouchard 364 

Bourgery 130,  156 

Bouveret    356 

Bowman 17,  112 

Brachet 15,  16,  17 

Bridge 326 

Brown    435 

Brown-Sequard 19 

Broussais 15,  16,  17 

Budd  276 

Budge 19,252 

Buffon 16 

Burgess   241 

Burdachi    33 


Cabanis    16 

Cautani 587 

Casenare    584 

Chapin 20,  21,  159 

Chaussier 14,  33,  34 

Clark 336,  431,  500 

Clay 18,  25,  156 

Clemm    639 

Cline 610 

Cohnheim 433 

Cohnstein 147,  158 

Collins 308 

Coons  606 

Cooper  18,  309,  310,  610 

Coutade    327 

Craigie 511 

Crisis 594 

Cruveilhier 19 

Curling 310 

Czerney    549 


D 


Dalrymple  25 

Dambo 147 

Darwin 436 

Davy 14,  15,  16,  17,  18 

Deaver    431 

DeCosta 334,  336 

Descartes  Reni     12 

Dietl 594,  597,  600,  645 

Donne 511 

Du  Boise 19 

Dun 356 

Durand 276 

Duverney 16,  655 


668 


LIST  OF  NAMES 


G69 


E 


Edebohls  

Einhoen 554 

Ellinger  

Erasistratus 12, 

Erhmann  

Eulenberg 18,  19,20,  21,  159, 

Eustachius 12,  22 

Evans 29,  112,  117,  119,335 


Pagb 

.595 
,584 

147 
,515 
.320 

190 
,  156 

570 


Farre 338 

Fellner 320 

Finney   608 

Fitch 407,  412 

Fleiner 356 

Fie  i  seller 365 

Fletcher 16,  17 

Fliess   : 658 

Flower 34 

Fox 21,  159,  189,  190,  326 

Frankenhauser  12, 

17,  IS,  26,  27,  88,  90,  130,  140,  141,  158,  159 

Francoise 29 

Frey 27,  526 

Frerichs 276 

Freund 130,  151,  156,  158,  346,  348 

Fruth 608 

Fuller 512 

Furbinger  276,  336 


Gail  15,  17 

Gallant  585,  614 

Galen  Claudius 11,  27 

Gallianet 589,  601,  620,  640 

Gaskell  21,  159 

Gasser 658 

Gasserius 654 

Gawvousky 158 

Gegenbauer 535 

Gerlachs 416 

Gerald 16,  268 

Gerota 530 

Gianozzi 19 

Gibbon  615 

Glenard 610 

547,   549,  553,   556,   562,   592,  605,  633,  640 

Goetz 18 

Goltz 146,  158,  313,  321 

Gooch 249,311 

Good 15,  234 

Graff  22 

Grant 16 

Gray 515 

Graves 19,  30 

Griesinger 20 

Gubler 21 

Gunn 16 

Guttman 18,  19,  20,  21,  159,  190,  336 

Guyon 327 

H 

Hall 16,  17,  18 

Hahn 606 


Pace 

Haller 16,  22,  67,  156 

Hammerschlag 527 

Hare 336 

Harlan    431 

Hartmans 426 

Hashimoto  Sabura 131,  153,  158,  175 

Head 295,  305,  398 

Hearst 21 

Heberden 19,  30,  312 

Hegar 345,  348,  349,  350,  631 

Heffer 19,  158 

Heister 427 

Hekton 328 

Heinicke — Mickulicz 585 

Henry 608,  609 

Henles 19,  35,  52,  71,  281,  326,  537 

Henrot 325 

Hermann 189 

Herophilus  12,  5]:, 

Hersh field 26,  158,  283,  289 

Hilton 280 

Hippocratis 12 

Hirsch 336,  488 

Hoare 14,  373 

Hofman 73 

Howlett 527 

Huber 16 

Hunter,  J 17,  23,  26,  312 

Hunter,  Wm 18,  23,  26,  156 

Hyrtl.  .79,  81,  127,  14S,  436,  440,  441,  487,  489 

J 

Jackhowitz    313 

Jacquemier  24 

Jaksch 336 

Jaggard    410 

Jans 654 

Jactreboff 131,  158 

Jastowitz  19,  181 

Jaylife 514 

Jobert,  J.  A 26 

Jobert,  De  Lamella 131 

Jreper 358 

Jung 131,  141,  158 

K 

Keher   549 

Kehrer 27,  141 

Keilmann 146,  158 

Keith 554 

Kerner  140 

Killian 18,  26,  27,  156 

Kirro 343 

Klein  338 

Kitagama 335,  336 

Klopper   490 

Knoll 19,  316 

Koch 27,  140,  158 

Kokitanskv  264 

Kolliker 19,  27,  326 

Kossman 547 

Krantz    348,  350 

Kraus    16 

Kressmaul  549 

Krehls 433 

Knjsinski 334,  335,  336 

Kunpffer 130,  158,  320 


: 


LIST  OF  NAMES 


Pacb 

Lancicus 

Lancereaux 313 

Landau 548 

Lambell     18,158 

Larastine  152 

Larage    

Lecorche 263 

Le  Gallois  14,  17 

Lee 17,  18,24,25,2  ;.  156,  159 

Legros   327 

Leube 334,  336, 

Leville - 

Leyden 

Lincolns 435 

Litten    335 

Littre 

Lloyd -r:-  42o,  642 

tein  16,  18,  24.  156,159 

Lohmer 350 

Lomer  29,  42,  96 

Longet    158 

Lucas B5,  42" 

Ludwig  . .  .19,  104,  168,  241,  242,  292,  32",  339 
Luschka  34 

M 

MacKellar 312.  61l 

Mayo 16,  615 

Martin 2.2,  203,  550 

Mayer 20,  158,  255,  320 

Manee 16 

Mathieu 330 

McNeil 414 

Meckel 14,  293,  408,  414,  419 

McBurneys -    104,416,417,427 

McKindrick 326 

Meinert 634 

Meirert 554 

Mering 315 

Meissner 241,  243,  244,  250,  292 

Meissner,  Billroth- 242 

Mitchell,  Weir 

Miller :    245,  2-52 

Minkowski 315 

Milliot 

Minot 35  5 

Morris 2,7.  556 

Morgangui 16,  33- 

Monro 14 

Muller 17 

Musser  431 

N 

Nagel 521 

Napier 

Nasse   19,  320,  32-; 

Naunyn 452 

Neelson 338 

Nothnagel 319, 

322.  323,  334.  335.  336,  33*.  3J 


iyrne 29,  112,  117,  427.  577,  57 

Onimus 327 

Oppoltzer  ,.  548 


Pace 

Osiander,  J.  F 23,  156 

Osiander 18,  156 

P 

Pacquet 517,  518 

Patherson 159 

Pariser 336 

Parry 19,  30 

Paw 30 

Perrond 336 

Pessimski 131,  150,  158 

Petit  16 

Philip 15 

Perier 363 

Pfeulers 19 

Pflueger 19,  320,  326 

Pick 3:!4.  336,  359,  367 

Pickford 19 

Pinel 14 

Poetal    5-7 

Polle 27 

Pouparts 30 

Powell 314 

P '-.rier   521 

Prochaska .14,  17 

R 

Rachel 334 

Radcliff 16 

Ralando 17 

Ranvier 520,  523 

Rauber 21,  159 

Rayer 547 

Recklinghausen 522,  523 

Reid 16 

Reil 16 

Rein 130,  131. •  146,  147 

Remak,  16,  19,  104,  140,  168,  241,  242,  292,  439 

Remond 654 

Reyner  de  Graff 156 

Richmond  and  Gall 15,  17 

Richardson 537 

Ribes 33,  254 

Rickets 131 

Riedel 550,  587,  588,  594 

Ries 531,  658 

Robin 16 

Rhorig 158 

Robinson  Bvron 

_      ■'.  130,  147,  158,  255,  285,  2^7,  291, 
295,    482,    521,  602,  603,  606,  623,  624,  »:27 

Rochefontaine 19 

Rokitansky 424 

Rollet 

Romberg 308,  310,  327,  363 

Rose  547,  585,  589,  593,  601,  614,615,620,  639 

Rosewater 601,  639 

Rothmann 336 

Rudbeck 514,  517,  516 

Rudolphi :....  16 

Ruge 336 

s 

Salvage  .      26 

Sam  son  von 414 

Santoeine 453 


LIST  OF  NAMES 


671 


Pace 

Sappev.  260,  516,  520, 

Savage 262,  289,  522 

pa 11 

Schanzoni 148 

Schiff IS 

Schroeder 616,64] 

Schlem 18 

Schmitz 603 

Schneiderian 

Schmidt 104,  168,  241,  242,  292,  439 

Schroder 549,  640 

Schiippel 27ti 

Schwerdt 268,  557 

Senn  N 405,  412,  616 

Sedlein 12 

Senator 36  1 

Sherren 398 

Sholer 564,  565 

Smith 31 

Solly IT 

Sommering 16 

Spugel 586 

Stiller 496,  553,  554,  630,  634 

Steinach 320 

Stilling 33 

Stober 421 

Stube 597 


Tait,  Lawson.,251,263,422,  424,  429,  431,  465 

Tanner 445,  533 

Tarchanoff 19 

Teichman,  517,  519,  525,  536,  540, 541,  542,  543 

Testut 518 

Theile 330 

Thompson 336 

Tiedemann..l8,  22,  23,  24.  26,  52,  130,    156 

Todd 17.  112 

Toldt 532,  534.  538.  539 

Treitz 571,  573 


Valentine 52,  .127.  657,  658 

Valleix's 274.  284 


TaC.E 

Van  Hook 

Vanni 

27,  4:<7 

Verworn 

Velpeau 

Vesalius 

Vidian 

Viensseni,  K 12.  14.  22.  42, 

Virchow 363,  511, 

Virchow-Robin 

Vogel 

Volkmann 19 

Vulpian 189 

\V 

Waite.  Lucy 268,  271    S 

347.   ,i!»4,  404,   109,  422,  533,  555.  610,  613 

Wagner 16 

Waldeyer 52,  158 

Walther 130 

Walter....     16,  19,  22.  24,25,  130,  156,  336 

Washburn 405 

Watzer 15,  17 

Weber 16,  327 

Wenzel 571 

Wesling 517 

Wild 381 

Wilford 16 

Windscheid -  3 

Williams 359 

Wilkes 430 

Willis   .  .  .12,  14,  15.  22,  33.  88.   112.  l.v  . 

Wirsing  

Winslow 14.  15.  408 

Wrisberg,   16,  35,  106,  112.  168,  249,  291,  312 

Wolffian. 597 

Woodward 334 

Wutzer 15,  17 

z 

Zetlitz 424 

Ziegenspeck 618 

Zinn.  . .  14 


QP368 
R56 
Robinson  1907 

Abdominal  and  pelvic  brain. 


